NUR310 Exam 1

A nurse is assessing a client with Crohn's disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series?

Colon perforation. When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn's disease.

What is primary enuresis?

children who have NEVER experienced a period of dryness *primary nocturnal = most common

Where do bacterial skin infections usually begin?

At the hair follicle, where bacteria easily collect and grow in the warm, moist environment.

What do Psoriasis lesions look like?

scaled with underlying dermal inflammation from an abnormality in the growth of epidermal cells

Pressure ulcer stage? Partial thickness loss of dermis presenting as a shallow open user with a red pink would bed, without slough. May also present as an intact or open/ruptured serum-filled or zero-sanguinous filled blister

Stage 2: partial thickness

What is stress incontinence?

Stress incontinence is the loss of less than 50 mL of urine during coughing, laughing, or sneezing. In women, this is often seen after having children. Kegel exercises increase the perineal muscle tone helping to control involuntary voiding.

A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report?

projectile vomiting Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material.

When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is:

scrambled eggs and applesauce Low-residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy. Barbecued foods are spicy; foods high in fat can increase peristalsis. Fruit and aged, sharp cheese can be irritating to the bowel. Chunky peanut butter and whole wheat bread are high-residue foods.

Reactivation stimulates the virus to travel down the ________ nerves to the skin where lesions reappear.

sensory

A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis than the client with Crohn's disease?

Involvement starting distally with rectal bleeding that spreads continuously up the colon. (In ulcerative colitis, pathology usually is in the descending colon; in Crohn's disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. There is no direct correlation of colitis with malignancy of the bowel, although psychologic, environmental, genetic, and nutritional factors, as well as preexisting disease, appear to be influential in malignancy. Involvement is in the distal portion of the colon, not the proximal portion.)

When comparing ulcerative colitis and Crohn's disease, a nurse considers that they are similar yet dissimilar in many ways. What clinical manifestation is common to clients with Crohn's disease and not to clients with ulcerative colitis?

RLQ pain (Right lower quadrant pain is typical with Crohn's disease; left lower quadrant pain is typical with ulcerative colitis.)

What are the physical risk factors of enureses?

-decreased bladder capacity -underlying urinary tract abnormalities -neurologic alterations -obstructive sleep apnea -constipation -UTI -pinworm infestation -diabetes mellitus -voiding dysfunction

What are emotional risk factors of enuresis?

-increased stress -family disruption -inappropriate pressure during toilet training -inadequate attention to voiding cues -decreased self esteem -sexual abuse

What are complications of herpes zoster? (4)

1. full-thickness skin necrosis 2. Bell's palsy 3. eye infection 4. scarring if virus is introduced into the eye

Peak age of UC diagnosis?

15-25, 55-65 Crohns = 15-40

How many negative readings does a MRSA patient need to have in order to come off precautions?

2

Varicella incubation?

21 days

How long does an outbreak of oral herpes simplex usually last? How long is it contagious?

3-10 days; 3-5 days

What nursing assessment best indicates the magnitude of fluid loss in an infant with gastroenteritis and diarrhea?

Comparing the infants pre-illness and current weights

How can MRSA spread?

Easily to other body areas or other people by direct contact with infected skin and by contact with clothing, linen, athletic equipment and other objects used by a person with MRSA

What type of infection is Tinea Pedis (Athlete's Foot)?

Fungal infection *contagious

A dehydrated infant with a several-day history of vomiting is admitted to the pediatric unit with the diagnosis of gastroenteritis. The nurse plans to monitor the infant's response to parenteral therapy. What is the best indicator of rehydration?

Increased weight (not # of wet diapers)

A mother brings her 6-month-old infant to the emergency department with a 3-day history of gastroenteritis. What priority intervention does the nurse anticipate?

Insertion of intravenous catheter

What are the most common systemic drugs used for extensive bacterial skin infections (especially if fever)?

Penicillins and cephalosporins. If allergic to above than: tetracyclines, macrocodes or amino glycoside antibiotics

Pressure ulcer stage? Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

Stage 4: Full thickness tissue loss

Incontinence that is unpredictable and often associated with neurological issues?

Total incontinence

A nurse is eliciting a health history from a client with ulcerative colitis. What factor does the nurse consider to be most likely associated with the client's colitis?

genetic predisposition (not autoimmune)

Relating to the genital and urinary organs?

genitourinary

Older adults with gastroenteritis need to be monitored for?

hypokalemia and dehydration (can become hypovolemic and experience electrolyte imbalances)

relating to illness caused by medical examination or treatment.?

iatrogenic

Where does a viral infection remain dormant after the first infection?

in the nerve ganglia

A client with a history of Crohn's disease develops an intestinal obstruction. An enteric catheter is inserted and connected to low continuous suction. The nurse monitors the client for fluid volume deficit. What clinical finding does the nurse expect if the client becomes dehydrated?

inelastic skin turgor

What reduces the risk of spreading the shingles virus to others?

keeping patients with fluid filled blisters separated from other patients until the lesions have crusted over

where is inflammation in Crohn's?

most often small intestine, the colon or both *most often affects the terminal ileum

What is secondary enuresis?

occurs when a 6-12 month period of dryness has preceded the onset of wetting.

Where is MRSA found?

on skin, perineum and in the nose

What is the main cause of diurnal enuresis?

overactive bladder (condition in which child experiences bladder spasms or increased urgency)

An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?

pair of gloves

Common areas of infection for Candida albicans?

perineum, vagina, axillae, under the breasts and in the mouth

Psoriasis patients often improve with more exposure to _____?

sunlight

What tool aids in the prevention of pressure ulcers?

the Braden Scale *less than 18 of 23 points considered at risk for pressure ulcers

What does ESR (erythrocyte sedimentation rate) measure?

the rate at which red blood cells fall through plasma.

Term used for a Dermatophyte (fungal) infection?

tinea (followed by location for ex. tinea pedis)

What is used to treat mild bacterial infections?

topical antibacterial treatment

What is autoinoculation?

transfer of either viral type from one part of the body to another

What are droplet precautions?

Mask, gown and gloves. indirect transmission, produced when a person talks or sneezes, travel short distances. Deposited in nasal, oral, or conjunctival membranes. Can only travel up to 3 feet. Ex. Influenza

Kid with little white spots on buccal area, respiratory symptoms (cough, runny nose), fever and malaise has?

Measles

A client is admitted to the hospital with a diagnosis of Crohn's disease. What is most important for the nurse to include in the teaching plan for this client?

Meeting nutritional needs To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised.

Kid with head and neck pain, neural rigidity, fever, malaise, poor sucking reflex?

Meningitis

Kid with pain in ear, jaw or chin, fever, muscle pain, pain when eating?

Mumps

A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence?

Offering the urinal regularly

Incontinence caused by over-distention of the bladder?

Overflow incontinence

An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client's elimination needs?

Taking the client to the bathroom at regular intervals removes responsibility from the client, who is having difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes of incontinence.

What is Candida albicans?

aka yeast infection and common fungal infection of skin and mucous membranes *if in mouth called "thrush" or oral candidiasis

A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to:

allow intestinal tract to rest

Treatment of meningitis?

antibiotics, hospitalization and droplet precautions -broad spectrum antibiotic to start

Treatment of measles?

antimicrobials, treat symptoms, provide appropriate nutrition and and want them to stay quiet and low key *airborne isolation room

Pressure ulcer stage? Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching but it's color may differ from the surrounding area

Stage 1: Non-blanchable erythema

The stool of a patient with UC usually contains?

blood and mucus (Crohn's is non-bloody)

How can patients spread bacterial skin infections to other parts of their bodies?

by scratching or rubbing the skin with fingernails.

Pressure ulcer stage? Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage 3: Full thickness skin loss

What does Surgical Asepsis mean?

Surgical asepsis means that the defined area will contain no microorganisms.

A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate?

Tachycardia is expected with dehydration because of a decrease in circulating fluid volume.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN) via an infusion pump. What is most important for the nurse to do when administering TPN?

change the TPN solution bad every 24 hours

What is enuresis?

children with difficulties in urinary control (can be nocturnal or diurnal) *more common in boys than girls

What is CRE and where does it live?

Carbopenem antibiotic (most often given for abdominal infections like peritonitis) resistant germs. Lives in GI system. *high risk patients = ICU and Nursing Homes

Incubation of mumps?

7 days before and 9 days after (on droplet precautions)

What drugs are used for treatment of viral infections?

Acyclovir (Zovirax), valacyclovir (valtrex) or famciclovir (Famvir)

What is eschar?

a dry scab covering; this makes it not possible to judge the stage of a wound.

Measles incubation time?

8-12 days.

Superficial infection only involving the upper portion of the hair follicle?

Folliculitis -caused by Staphylococcus -rash is raised and red and usually shows small pustules

A boy in kindergarten has experienced urinary incontinence during the first few weeks of school. What should the school nurse do?

Keep a change of clothes available for him in the health office

How diagnose Meningitis?

Lumbar puncture, draw blood culture

What manifestations are common in UC patients?

Malaise, anorexia, anemia, dehydration, fever and weight loss

What is the most common cause of skin cancer deaths?

Malignant Melanoma, a tumor that develops from melanin-producing skin and mucosal cells. *white individuals 10x more likely to die from Melanoma than African-Americans.

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally, the nurse should discuss the concerns with:

Adult protective services. The nurse has a legal responsibility to report suspicions of abuse to the appropriate agency, which in this instance is Adult Protective Services.

A health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do?

Avoid activities requiring alertness until response to the medication is knowTolterodine , a urinary tract antispasmotic, may cause dizziness and blurred vision, placing the client at risk for injury.

A client, experiencing an exacerbation of Crohn's disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness?

Bacteria meningitis. The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people.

Inflammation of the skin and subcutaneous tissues, often caused by Staphylococcus aureus or streptococcal infection following a break in skin integrity such as a minor laceration or surgical incision?

Cellulitis (bacterial infection) *a hot, tender, reddened area of local infections develops at the site of injury. *individual may experience a generalized response to the infection such as fever and malaise.

A nurse is performing a physical assessment of a client with ulcerative colitis. The finding most often associated with a serious complication of this disorder is:

Decreased bowel sounds (Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon. Loose, blood-tinged stools are an uncomfortable but less serious manifestation. Distention of the abdomen is an expected response that is not of primary concern at this time. Intense pain is a symptom of ulcerative colitis, not a complication.)

incontinence associated with environmental or cognitive factors in which the client is unable to get to the toilet?

Functional incontinence

Infection that is much deeper in the follicle?

Furuncles -also caused by Staphylococcus -larger, sore-looking, raised bump that may or may not have a pustular head. -most often occur in areas with heat and moisture (such as hair-bearing skin fold areas)

Common health problem world wide that causes diarrhea and vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract?

Gastroenteritis *can be viral or bacterial but viral most common

What are contact precautions and when are they used?

Gown and gloves. Used on pt with infectious organism that could easily be spread to someone else by touching or contact. (open sores, lesions, MRSA, CDIF etc.)

What are airborne precautions and when are they used?

Gown, gloves & respirator on before entering room. For patient w/ illness caused by a germ that can travel through the air long distances. Pts should be placed in a special room called a negative pressure room. Negative pressure rooms prevent the air from flowing into the hallways. Tuberculosis and chicken pox are examples of illnesses that would require a patient to be placed in airborne precautions.

What is the most common adult viral skin infection?

Herpes Simplex Virus (HSV) 2 types: Type 1 = cold sore, Type II = genital herpes

What form of herpes occurs on the fingertips of health care personnel and can spread easily to patients?

Herpetic whitlow

What is used to treat MRSA or other drug-resistant organisms?

IV Vancomycin or oral linezolid or clindamycin

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

Institute measures to prevent constipation. A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence.

A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. The nurse expects that the electrolyte deficiency will be corrected by:

Intravenous therapy

A chronic, autoimmune disorder affecting the skin with exacerbations and remissions and results from overstimulation of the immune system in the skin that activates T-lymphocytes?

Psoriasis

Transmission of infection agents requires what 3 factors?

Reservoirs (or source) of infectious agents (people, animals, water, soil, etc), Susceptible host with portal of entry, and mode of transmission.

What are routes of transmission?

Respiratory tract GI tract Genitourinary tract Skin/mucous membranes Bloodstream

Kid with rash and similar manifestations of measles?

Rubella (German measles)

A contagious skin infection caused by mite infestation?

Scabies

What is postherpetic neuralgia and in what demographic is it common?

Severe pain persisting after shingles lesions have resolved; common in older patients

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. What should the nurse teach the parents?

The child will probably require a program of intermittent straight catheterization.

A nurse in the pediatric clinic is planning care for a 7-year-old boy with enuresis. What is an appropriate short-term goal for this child?

The length between voidings will increase by 1 hour. Lengthening the time between voidings is a short-term goal that can be measured in increments of 1 or more hours between each voiding, providing a measurable sign of improvement.

What is pediculosis?

a lice infestation pediculosis capitis = head lice pediculosis corporis = body lice pediculosis pubis = pubic lice/crabs

True or False. Skin infections can be bacterial, viral or fungal.

True.

Pressure ulcer stage? Full thickness skin or tissue loss - depth unknown. Depth of ulcer completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Unstageable/Unclassified.

The nurse determines that which genitourinary factor contributes to urinary incontinence in older adults?

Urinary tract infections affect the genitourinary tract and interfere with voluntary control of micturition. Sensory deprivation is a neurological, not a genitourinary, factor. Frequent use of diuretics is an iatrogenic, not genitourinary, factor. Inaccessibility of a bathroom is an environmental, not genitourinary, factor.

What is #1 MRSA drug?

Vancomycin *requires close monitoring - use peak/trough levels!!

What is VRE and where does VRE live?

Vancomycin resistant bacteria. Lives in intestines

Kid with fever, malaise and anorexia?

Varicella

A nurse is caring for an infant with gastroenteritis and diarrhea. What should the nurse evaluate to determine the magnitude of the infant's fluid loss?

Weight compared with prior weight Loss of weight is the most accurate measurement of the magnitude of fluid loss; 1 L of fluid weighs 2.2 lb

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, bland, high-protein diet and parental vitamins B, C, and K have been prescribed. The nurse explains that this dietary regimen is designed to reduce:

colonic irritation A low-residue, bland diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, absorption. Electrolyte depletion may be prevented by reducing colonic irritation, but this is a secondary benefit.

Manifestation of scabies?

curved or liner ridges in the skin (formed by burrowing of the mite into outer skin layers)

What can happen if MRSA infects a wound or enters the bloodstream?

deep wound infection, sepsis, organ damage or death can occur. *infection does NOT respond to antibacterial soap, or most topical or oral antibiotic therapies

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration?

depressed anterior fontanel A depressed anterior fontanel is a classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid.

A nurse is planning play activities for a 6-year-old child whose energy level has improved after an acute episode of gastroenteritis. What activity should the nurse encourage?

drawing or writing with a pencil or marker

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client?

electrolyte imbalances An ileostomy directs liquid feces out of the body, bypassing the large intestine where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance

A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's blood chloride level is decreased. What is the most efficient way this can be corrected?

intravenous therapy Intravenous therapy ensures a rapid, well-controlled technique for electrolyte (chloride) replacement.

Where is inflammation with Ulcerative colitis?

mainly the rectum and rectosigmoid colon, but can extend to the entire colon if disease is extensive

Herpes zoster (shingles) is an infection caused by reactivation of?

varicella-zoster virus (VZV) in patients who have previously had chicken pox *most common in older people or anyone who is immunosuppressed. *IS CONTAGIOUS in those who have not had chicken pox or the vaccine