Nursing 10 Exam 2
A) increased heart rate
A client admitted to the unit is visibly anxious. When assessing this client, the nurse should expect to see which cardiovascular effect produced by the sympathetic nervous system? A) increased heart rate B) decreased BP C) decreased pulse rate D) syncope
deep tissue injury purple or maroon localized area of disclosed intact skin or blood-filled blister due to damage to underlying soft tissue from pressure or shea, or both
Define DTI
Atrophy of the muscle layers and mucosa Decrease in contraction of the muscle wall when the rectum is filled with stool, resulting in constipation Diverticuli are prevalent
Identify age-related variables that influence bowel elimination in the older adult
transduction: activation of pain receptors transmission: conduction along pathways (A-delta and C-delta fibers) perception of pain: awareness of the characteristics of pain modulation: inhibition or modification of pain
Pain process
patient-centered care teamwork and collaboration evidence-based practice quality improvement safety informatics
QSEN Competencies
lent: all animal products, including diary products, are forbidden fasting occurs during advent exceptions: pregnant women, children, and ill
Restrictions on Eastern Orthodox diet
many are vegetarian, if they eat meat do not eat beef or pork fasting rituals vary children are not allowed to participate in fasting
Restrictions on Hinduism diet
nociceptive cutaneous somatic visceral neuropathic
Sources of pain
attack, withdrawal, and compromise
Task-Oriented Reactions to Stress
C) place the client on a pressure redistribution bed
The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? A) place a foam pad on the existing mattress B) turn the client every 2-4 hours C) place the client on a pressure redistribution bed D) administer pain medications as ordered
serum albumin, pre-albumin, transferrin
What 3 lab values should you, as the patients nurse, check for nutrition values
carbs, protein and fats
What nutrients provide energy for the body?
rapid onset and relatively short duration and a sign of a new health problem requiring diagnosis and analgesia treat underlying cause: short term analgesia
define acute pain and how its treated
full-thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar can be present on some parts of wound bed. often includes undermining and tunneling typical healing time: 6-12 months (often never heals)
Define stage IV pressure ulcer
fecal impaction
Effects of immobility on the GI system
alcohol, coffee, and tea consumption of meat is limited first sunday of the month is optional for fasting
restrictions on mormon diet
D) keeping the perineal area clean and dry
A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? A) maintaining a fluid intake of 1 L/day B) offering the client the urinal every 3 days C) applying moist, warm compresses to the client's groin D) keeping the perineal area clean and dry
A) perform ROM exercised D) encourage the client to eat a well-balanced diet E) reposition the client every 2 hours
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A) perform ROM exercised B) use commercial soaps to keep the skin dry C) tuck bed covers tightly into the foot of the bed D) encourage the client to eat a well-balanced diet E) reposition the client every 2 hours
1. all team members are considered caregivers 2. care is based on continuous healing relationships 3. care is customized and reflects patient needs, values, and choices 4. knowledge and information are freely shared between and among patients, care partners, physicians, and caregivers 5. care is provided in a healing environment of comfort, peace, and support 6. families and friends of the patient are considered an essential part of the care team 7. patient safety is a visible priority 8. transparency is the rule in the care of the patient 9. all caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient 10. the patient is the source of control for their care
What are the vital principles of person-centered care?
D) turn him regularly
A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? A) perform passive ROM exercises B) encourage fluid intake C) message bony prominences D) turn him regularly
D) constipation
A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics routinely for pain. The nurse should focus her follow-up assessment on which complication? A) diarrhea B) anorexia C) anxiety D) constipation
D) lean meats and low-fat milk
A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? A) legumes and cheese B) whole grain products C) fruits and vegetables D) lean meats and low-fat milk
D) encourage the client to ambulate
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do? A) insert an NG tube B) encourage the client to drink carbonated liquids C) insert a rectal tube D) encourage the client to ambulate
atrophy of heart muscle, DVT, postural hypotension
Effects of immobility on the cardiovascular system
calculi, nephritis
Effects of immobility on the endocrine system
anemia
Effects of immobility on the hematologic system
osteoporosis, atrophy, contracture, foot drop
Effects of immobility on the muscloskeletal system
depression, psychosis
Effects of immobility on the neurological system
risk for pnuemonia, risk for PE, and atelectasis
Effects of immobility on the respiratory system
albumin: <3.5 g/dL transferrin: <200 mg/dL (mild-moderate) <100 mg/dL (severe) pre-albumin: 5-15 mg/dL (mild) <5 mg/dL (severe)
Lab values indicative of malnutrition in some degree
2 inches it's important because if she gets a UTI, it is short, and infection can travel to other areas quickly
How long is a females urethra? Why is this important to note?
two: reflex pain response and inflammatory response
How many types of LAS are there?
Females: 100lbs (for height of 5ft) +/- 5lbs for each additional inch over 5ft Males: 106 lbs (for hight of 5ft) +/- 6 lbs for each additional inch over 5 ft
IBW formula
bladder capacity decreases prevalence of involuntary bladder contractions increases nocturia decrease in bladder contractility which can lead to retention and stasis then that can lead to UTI Females have decreased levels of estrogen, multiple pregnancies, increase in friability of urethral mucosa Males prostatic hypertrophy
What are some age-related risk factors for urinary incontinence?
dementia, delirium, drinking alcohol, drug use, dysphagia, deafness, depression, desertion, destitution, despair
What are the 11 D's of Failure to Thrive
affects of physical status increases risk for disease or injury compromises recovery and return to normal function is associated with specific disease
What are the effects of Long-Term Stress?
important hormone-like substances that send additional pain stimuli to the CNS
What do the prostaglandins have to do with pain?
F=formulate and document an individuals prevention plan of care L=lift the heels off the bed O=observe the heels daily A=apply protective products as needed T=turn and reposition based on the individuals plan of care
What does "FLOAT" stand for?
localized response of the body to stress involves only a specific body part, instead of the whole body stress precipitating the LAS may be traumatic or pathologic primarily homeostatic short-term adaptive response
What is Local Adaptation Syndrome (LAS)?
comprehensive evaluation of a patient's nutritional status and typically includes data collection in each of the following areas: demographic and psychosocial data, medical history, dietary history, anthropometrics, medications and laboratory values, and a physical assessment
What is a nutritional assessment?
2,000 mL to 2,500 mL for a normal healthy individual
What is an adequate amount of fluid intake daily?
powerful vasodilator that increases capillary permeability and constricts smooth muscle
What is bradykinin?
result or outcome of critical thinking or clinical reasoning conclusion, decision opinion related to patient problems
What is clinical judgment?
ways of thinking about patient care issues determines, prevents, and manages
What is clinical reasoning?
kidneys, ureters, bladder, and urethra
What is included in the urinary tract?
Assessing Diagnosing Planning Implementing Evaluating
What is patient-centered nursing process?
acute urinary retention bladder obstruction improve comfort for end-of-life measures critically ill for accurate I &O assist in healing open/peri-wound selected surgical procedures
What is the criteria for the use of a catheter?
mind-body interaction coping mechanisms anxiety (mild, moderate, severe, panic)
What is the emotional response to stress?
M=17-27% F=28-41% SNFs=50-75%
What is the prevalence of urinary incontinence in males? females? and in skilled nursing facilities (SNFs)
urge
What type of incontinence is described? Patient has to urinate every time he or she hears water running.
functional
What type of incontinence is described? Patient is depressed and does not participate in anything.
overflow
What type of incontinence is described? Patient with multiple sclerosis
B) exposure to moisture
When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer? A) smoking B) exposure to moisture C) presence of HTN D) client's gender
A) have the client urinate on a timed schedule
Which nursing action is most appropriate for a client who has urge incontinence? A) have the client urinate on a timed schedule B) teach the client intermittent self-catheterization technique C) provide a bedside commode D) administer prophylactic antibiotics
A) test for blanching to the affected area
Which of the following is a priority nursing assessment of a reddened heel in a bed-ridden client? A) test for blanching to the affected area B) use powder to minimize shear forces to both heels C) check for perspiration and remove all linen to the extremity D) rub the reddened area above and below the site
C) the client's skin is intact with non-blanchable redness of a localized area over a bony prominence
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? A) the client's skin is a shiny, dry ulceration with bruising noted B) the client's subcutaneous tissue is visible with a blood blistered wound bed C) the client's skin is intact with non-blanchable redness of a localized area over a bony prominence D) the client's skin has partial loss of dermis presenting as a shallow open ulcer with a red pink wound bed
mild-moderate pain poorly tolerated or inadequately managed with mild analgesic, consider using an opioid analgesics problems with opioids usually involve those with long half-lives moderate-severe pain can be relieved with hydrocodone, oxycodone, hydromorphone, oxymorphone, or imediate-release morphone
opioid analgesics
relaxation, meditation, anticipatory guidance, guided imagery, biofeedback, crisis intervention
Stress management techniques
D) acknowledge the client's right to make the choices regarding treatment
A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the most appropriate action by the nurse in relation to the client's requests? A) tell the client that the family or POA must agree with these decisions B) inform the client that the physician is best available to make treatment decisions C) persuade the client to continue chemo along with better pain management D) acknowledge the client's right to make the choices regarding treatment
A) incontinence and right-sided hemiparesis
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk for skin breakdown? A) incontinence and right-sided hemiparesis B) demonstration of neglect of left side of the body C) unwillingness to ask for assistance D) inability to express need for repositioning
Sensory perception Moisture Activity Mobility Nutrition Friction and Shear (Some Men Are Mean, Nice, or Fiesty)
Braden Scale Risk Factors
the energy required to carry on the involuntary activities of the body at rest
Define basal metabolism
A systematic way to form and shape one's thinking functions purposely and exactingly disciplined, comprehensive, and based on intellectual standards, and well-reasoned
Define critical thinking.
patient's verbalization and description of pain duration of pain location of pain quantity and intensity of pain quality of pain chronology of pain aggravating and alleviating factors physiologic indicators of pain behavioral responses effect of pain on activities and lifestyle
General assessments of pain
pork, birds of prey, alcohol, and any meat product not ritually slaughtered are prohibited month of Ramadan, fasting occurs during the day-time; some individuals may be exempts from fasting (pregnant women)
Restrictions on Islam diet
any foods to which blood has been added are prohibited
Restrictions on Jehovah's witnesses diet
orthodox: kosher--meats allowed include animals that are vegetable eaters, cloven-hoofed animals, and animals that are ritually slaughtered, fish that have scales and fins are allowed, any combination of meat and milk are prohibited Yom Kippur: 24-hour fasting is observed (exempt-children, pregnant women, and ill) Passover: only unleavened bread is eaten
Restrictions on Judaism diet
alcohol is prohibited avoid consumption of anything to which blood has been added some avoid pork
Restrictions on Pentecostal diet
exercise, rest and sleep, nutrition, use of support systems, use of stress management techniques
Teaching healthy ADLs
straight, foley/indwelling, 3-way
Types of catheters?
continues after healing or is not amenable to a cure, usually no autonomic signs and is associated with longstanding functional and psychologic impairment
define chronic pain
pathophysiologic process involving the PNS or CNS does not respond as predictably to analgesic therapy responds to unconventional analgesic drugs (tricyclic antidepressants, anticonvulsants, or antiarrhythmic drugs)
define neuropathic pain and how its treated
B) evaluation
A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using? A) diagnosis B) evaluation C) implementation D) assessment
a diminished response to a drug so that more medication is required to achieve the same effect
A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as?
C) a relaxation tape is playing in one corner of the room, and a TV airing special on crime is playing in the opposite corner
A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is most likely the occurrence that is disturbing to this client? A) a housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the day room B) there is only one other client in the dayroom; the rest are in a group session in another room C) a relaxation tape is playing in one corner of the room, and a TV airing special on crime is playing in the opposite corner D) there are 3 staff members and a HCP in the nurse's station working on charting
A) avoid alcohol and caffeine
A client with stress incontinence asks the nurse what kind of diet she should follow at home. The nurse should recommend that the client A) avoid alcohol and caffiene B) decrease fluid intake C) increase her intake of fruit juice D) avoid milk products
D) stress incontinence
A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: A) reflex incontinence B) functional incontinence C) total incontinence D) stress incontinence
reposition the client off the reddened skin and reassess in a few hours
A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to...
A) Ring or donut
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? A) Ring or donut B) Gel flotation pad C) Specialty mattress D) Water bed
A) stop the flow of urine while urinating
A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises? A) stop the flow of urine while urinating B) tighten stomach muscles C) lift both legs while lying down D) do pelvic squats
B) "i need to use laxatives regularly to prevent constipation"
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? A) "i will eat raw, green-leafy vegetables, unpeeled fruit, and whole grain bread" B) "i need to use laxatives regularly to prevent constipation" C) "i should try to drink twice as much water as I now" D) "i will take my dog for a walk every day"
weakness of one entire side of the body
Define hemiparesis
intact skin with nonblanchable redness of localized area, usually over a bony prominence typical healing time: 1-7 days
Define stage I pressure ulcer
partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. can also present as an intact or open/ruptured serum-filled blister typical healing time: 5 days to 3 months
Define stage II pressure ulcer
full-thickness tissue loss. subcut fat can be visible but bone, tendon, or muscle is not exposed. slough may be present but does not obscure the depth of tissue loss. can include undermining and tunneling typical healing time: 1-6 months
Define stage III pressure ulcer
pressure ulcer
Effects of immobility on the integumetary system
negative nitrogen balance, glucose tolerance
Effects of immobility on the metabolic system
B) oatmeal, milk, grapefruit wedges, and bran muffin
The nurse has been teaching the client about maintaining a high-fiber diet. The client's selection of which breakfast menu indicates an understanding of the instructions? A) scrambled eggs, bacon, english muffin, and apple juice B) oatmeal, milk, grapefruit wedges, and bran muffin C) corn flakes, milk, wheat toast, and oj D) danish pastry, prune juice, coffee, and milk
D) take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain
The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? A) take analgesics only when pain returns B) take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain C) get used to some pain, and use a little less medication than needed to keep from being addicted D) take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain
location, area (measure diameter for circular lesions, length and width for irregularly shaped lesions), depth, drainage, necrosis, granulation, cellulitis
Things to chart when documenting a pressure ulcer
A) shift your weight every 15 minutes
To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? A) shift your weight every 15 minutes B) bathe daily C) move from the bed to the wheelchair every 2 hours D) eat a high-carb diet
when the carer and the cared for is used for promoting or restoring the health and well-being of people within the relationship
What is a therapeutic relationship?
WBC, CBC, pre-albumin, possible cultures, Hgb A1C
What labs should the rn check when assessing pressure ulcers, and/or risk for pressure ulcers
location, size, color %, stage, thickness, exudate, undermining, tunneling, peri-wound, pain, photo with rule and measurements, marker to sign and date dressing
What needs to be documented in the chart regarding pressure ulcers?
stress
What type of incontinence is described? Laughing causes urine to leak out
stress
What type of incontinence is described? Lifting a heavy object results in leakage
functional
What type of incontinence is described? Nursing assistant left the walker out of the patient's reach
overflow
What type of incontinence is described? Patient had a nerve injury after a car accident
urge
What type of incontinence is described? Patient has an acute UTI
A) reassessing the client after administering pain medication
Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer? A) reassessing the client after administering pain medication B) reassuring the client after administering pain medication C) readjusting the pain medication dosage as needed D) repositioning the client immediately after administering pain medication
C) establish a regular voiding schedule
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? A) administer prophylactic antibiotics, as prescribed B) insert an indwelling urinary catheter C) establish a regular voiding schedule D) limit fluid intake to 1,000 mL/day
first-line approach to pain management acetaminophen, ibuprofen, and naproxen block pain by inhibiting pain reception at local level acetaminophen is drug of choice for musculoskeletal pain; does not affect platelet levels (adult max dosage is 4000mg/24hours)
nonopioid analgesics
avoid meat on ash wednesday and fridays of lent optional fasting during lent season children, pregnant women and ill individuals are exempt from fasting
restrictions to roman catholicism diet
B) involuntary urination with minimal warning
A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has: A) inability to empty the bladder B) involuntary urination with minimal warning C) frequent dribbling of urine D) urge of urine when coughing
alcohol and caffeinated beverages lacto-ovo vegetarians meat eaters-->avoid pork overeating is prohibitied! (5-6 hours btwn meals without snacking)
Restrictions to 7th day adventist diet
alcohol lacto-ovo vegetarians some eat fish, and some avoid only beef
Restrictions to buddhism diet
FALSE! The lower the score, the higher the risk The higher the score, the lower the risk
T/F The lower the Braden Scale Assesment Score, the lower the risk of developing a pressure ulcer
C) stage II pressure ulcer
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? A) stage III pressure ulcer B) stage IV pressure ulcer C) stage II pressure ulcer D) stage I pressure ulcer
B) Administering analgesics on a regular basis, with administration of additional analgesics for break-through pain.
The nurse is collaborating with the physician to develop a care plan to help control chronic pain in a client with cancer who is receiving hospice home care. Which of the following plans would be most appropriate for managing the client's pain? A) Encouraging the client to avoid intravenous pain medication until the client's condition has reached the terminal stage. B) Administering analgesics on a regular basis, with administration of additional analgesics for break-through pain. C) Keeping the client sedated with tranquilizers to prevent awareness of pain sensations. D) Administering analgesics when the client's vital signs indicate that the severity of the pain is increasing.
B) reposition every 2 hours C) request an alternating-pressure mattress E) cover with protective dressing
The nurse is planning care for an older adult with a pressure ulcer. What should the nurse do? Select all that apply A) obtain daily cultures B) reposition every 2 hours C) request an alternating-pressure mattress D) elevated the HOB to 50 degrees E) cover with protective dressing
clear liquid full liquid regular low sodium, low fat, low cholesterol diabetic (dr. will order calories) vegetarian vegan Kosher Hallal
Types of diets in the hospital
stress: neurogenic, laughing causes leakage urge: acute UTI, feeling like always having to go functional: use of a walker/cane therefore slower to bathroom, dementia, difficult to get to overflow: urethral blockage so it cannot empty properly
Types of incontence
C) nutrition support and orthotics
Which disciplines should be consulted when caring for a client with a stage III heel ulcer? A) plastic surgery and cardiology B) PT and RT C) nutrition support and orthotics D) OT and infectious disease
cleaning the area around the urethral meatus
Which nursing intervention for catheter care should have the highest point?
full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar, or both, in the wound bed. until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined.
Define unstageable pressure ulcer
overweight/underweight easily fatigued, weakness, SOB dry brittle hair skin is dry, flakey, and pale pale conjunctiva peripheral edema poor muscle tone
Signs and symptoms of poor nutrition
D) elevate the HOB to 90 degrees during meals
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should: A) place the client in a supine position B) encourage the client to remove dentures C) encourage thin liquids for dietary intake D) elevate the HOB to 90 degrees during meals
A) repositioning every hour
Which action would be most helpful in preventing pressure ulcer formation in an at-risk client? A) repositioning every hour B) massaging reddened areas on the sacrum C) providing a low-protein diet D) ensuring a generous fluid intake
sensitizes receptors on nerves to feel pain and also increases the rate of firing nerves
What is substance P?
D) call the physician to report the finding
A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? A) repeat the dose of analgesia every hour B) massage the client's foot in a circular motion C) apply warm, moist heat to the right ankle area D) call the physician to report the finding
self-aware genuine/authentic effective communicator curious and inquisitive alert to context reflective and self-corrective analytical and insightful logical and intuitive confident and resilent honest and upright autonomous/responsible careful and prudent open and fair-minded sensitive to diversity creative realistic and practical proactive courageous patient and persistent flexible health-oriented inprovement-oriented
What are the personal critical thinking indicators?
visceral or somatic, usually a result of stimulation of pain receptors; may arise from tissue inflammation, mechanical deformation, ongoing injury, or destruction of tissue responds well to common analgesic medication and nonpharmacologic strategies
define nociceptive pain and how its treated
