Exam 4 Flashcards
(110 cards)
1
Q
what is the #1 factor affecting skin integrity?
A
impaired circulation
2
Q
of the following factors, which would put a client at the greatest risk for impaired skin integrity?
A. medication
B. moisture
C. decreased sensation
D. dehydration
A
C.
3
Q
Acute wound
chronic wound
A
acute= new
chronic= ongoing
4
Q
clean
contaminated
infected
A
clean= surgical
contaminated= major break (infection is high)
infection= 1000 organisms per gram of tissue (high risk for breakdown)
5
Q
which layers of skin are damaged in:
superficial
partial
full-thickness
A
superfical= epidermis (friction and sheer)
partial= epidermis in to dermis
full-thickness= subQ and beyond
6
Q
hemorrhage
A
forms in 24-48hrs.
swelling, pain, and vital changes may occur
7
Q
dehiscence
evisceration
A
d= rupture or separation of 1 or more layers (bursting open of a wound)
e= total separation of the wound (removal of the contents of a cavity)
8
Q
wound care
A
cleansing/irrigating
debriding
changing the dressing
heat/cold
9
Q
how are pressure injuries caused
A
unrelieved pressure to an area, resulting in ischemia
10
Q
pressure injury intrinsic factors
A
immobility, impaired sensation, poor nutrition, dehydration, aging, fever/infection, edema
11
Q
pressure injury extrinsic factors
A
friction, pressure, shearing, moisture
12
Q
how many stages are there of a pressure injury?
A
4 stages
DTI
unstageable
13
Q
stage 1 of a pressure injury
A
discoloration will remain for more than 30 minutes after pressure is relieved
14
Q
stage 2 of a pressure injury
A
partial-thickness loss of skin (epidermis)
wound bed is visable
15
Q
stage 3 of a pressure injury
A
full-thickness loss (adipose is visible)
tunneling may occur
16
Q
stage 4 of a pressure injury
A
full-thickness and tissue loss
slough and eschar. ebole (rolled edges)
tunneling may occur
clinicians should assess for osteomyelitis
17
Q
stage (DTI) deep tissue pressure injury
under the skin
A
intact or non-intact skin
pain and temp. change
damage of underlying soft tissue (from pressure or sheer)
18
Q
unstageable pressure injury
A
full-thickness loss
unsure of the extent of injury from slough and eschar
19
Q
which patient are checked for risk assessment
A
ALL patients
20
Q
when are reassessments done?
A
every 24hr- minimum
every 12hr- best practice
21
Q
when are skin reassessments done?
A
every 8-24 hours
22
Q
Braden score
A
6-23
lower the score the higher the risk
23
Q
skin with too little moisture is how many times likely to ulcerate
A
2.5
24
Q
skin with too much moisture is how many times likely to ulcerate
A
5
25
how high should the HOB be?
<30
26
the nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. which of these actions should the nurse take first?
A. don sterile gloves
B. provide analgesic medication as ordered
C. avoid accidentally removing the drain
D. gather supplies
B.
it is important the patient is out of pain before wound care is done
27
A client has been lying on her back for 2 hours. when the nurse turns her, she notices the skin over her sacrum is very white. by the time the nurse finishes repositioning her, the spot has turned bright red. the nurse should:
A. massage the spot with lotion
B. apply a warm compress for 30 minutes
C. return in 30-45 minutes to see if the redness disappeared
D. wash the area with soap and water and notify the physician
C.
you want to reposition the patient first
28
during evening care, the student nurse assesses the mepilex dressing on his client's sacrum. the dressing was dated and initialed for earlier that day. the dressing was attached on all edges with no visible drainage present. which of the following is most appropriate for the student nurse to document regarding the assessment?
A. base/site assessment clean, dry, intact
B. peri-wound clean, dry, intact
C. wound healing ridge clean, dry, intact
D. dressing clean, dry, and intact
D.
29
when assessing a wound, what do you all check?
location
size (in cm)
appearance
drainage
redness
swelling
30
where do wounds heal faster?
stabilized areas
31
what color is eschar and where is it located
tan, brown, black
on wound bed
32
what color is slough and where is it located
yellow, tan, brown, green, grey
in the wound bed
33
what is granulation tisse?
deep pink or red, moist, glistens on irregular granular surface
34
what documented for peri-wound skin and wound edges
pain
edema
induration (hardness)
erythema (redness)
maceration (white-wet)
35
what is:
abrasion
laceration
abrasion= wearing away of the upper layer of skin as a result of applied friction
laceration= deep cut or tear into the skin
36
what is ecchymosis
reddish to bluish discoloration of the skin, from the rupture of blood capillaries beneath the skin
37
what is a hematoma
swelling filled with blood, from a break in a blood vessel
38
the client calls the nurse to the room and states, "look, my incision is popping open when they did my hip surgery!" the nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. what is the nurse's best action?
A. notify the surgeon STAT
B. place a clean, sterile 4x4 over the incision and monitor the drainage
C. wrap with ace bandage firmly around the area and have the client maintain bedrest
D. immediately cover the wound with sterile towels soaked in saline and call the surgeon
B.
the nurse needs to sterilize the wound first to see if it prevents the wound to get worst
39
T.A.C.O
type
amount
consistency
odor
40
serous exudate
sanguineous
serosanguineous
purulent
purosanguineous exudate
serous exudate- thin, clear, watery plasma
sanguineous- bloody drainage
serosanguineous- thin, watery, pale red to pink plasma cells with red blood cells
purulent- thick, opaque drainage that is tan, yellow, green, or brown (pus)
purosanguineous exudate- blood and pus
41
scant
wound is moist, no visible drainage
42
low viscoisty=
thin, runny
43
what is the normal urine output
per day
per hour
per day= 1500mL
per hour= 40-60 mL
44
where are nephrons located and what do they do
located in the kidney, serve as a filter
45
what do ureters do
transport urine from the kidneys to the bladder
46
what does the bladder do
holds urine
47
what does the urethra do
who has a longer urethra? men or women
excretes urine from the bladder
men have a longer urethra (8 inches)
women (1.5-2.5 inches)
48
factors affecting urinary elimination
personal, religion, environment, nutrition, activity, medication
49
pathological conditions affecting urinary elimination
kidney infection, kidney stones, prostate (male), neurological condition
50
nocturia
polyuria
oliguria
anuria
dysuria
diuresis
enuresis
nocturia- nighttime bed wetting
polyuria- excess urination
oliguria- decrease urine output
anuria- the absence of urine
dysuria- painful urination
diuresis- an increase from caffeine
enuresis- involuntary loss of urine
51
pyuria
pyelonephritis
cystitis
pyuria- pus in urine
pyelonephritis- infection spread to upper kidneys
cystitis- bladder infection
52
medical alterations in urinary elimination
UTI, urinary retention, urinary incontinence, urinary diversion
53
what is usually done to manage urinary retention
catheterization
54
nursing intervention for managing urinary incontinence
toileting schedule (bladder training), kegel exercises, anti-incontinence devices
55
urine assessment
color, clarity, odor, amount
56
small intestine
aids in digestion and absorption
turns food into chyme
divided into 3 sections (D, J, I)
57
large intestine
the cecum, ascending colon, transverse colon, descending colon, sigmoid, rectum, anus
58
what are factors affecting bowel elimination
developmental stage, personal factors, nutrition, medications, pregnancy, ileostomy, colostomy
59
bowel function assessment
elimination pattern, routine, appetite, nutrition, surgery, medications, mobility
60
stool assessment
meds, color, consistency, amount
61
there is a 24-hour urine collection in process for a client. the nursing assistive personnel (NAP) inadvertently empties one specimen into the toilet instead of the hat. the nurse should?
A. continue with the collection of urine until the 24 hour period is finished
B. dispose of the urine already collected and begin an entirely new 24 hour collection
C. make a note to the lab to inform them that one specimen was missed during the collection time
D. begin filling a new collection container and take both containers to the lab at the end of the collection period
B.
if one specimen is accidentally disposed, you have to start over
62
you are caring for a patient who had an indwelling catheter removed 12 hours ago. the patient has not voided. what action should you take?
assess
palpate
bladder scan
63
the nurse is assisting the client in caring for her ostomy. the client states, "Oh, this is so disgusting. I'll never be able to touch this thing." the nurse's best response is?
A. it sounds like you are really upset
B. yes, it is pretty messy, so I'll take care of you today.
C. you sound very angry. should I call the chaplain for you?
D. I am sure you will get used to takin care of it eventually
A.
64
Sleep vs Rest
sleep= altered consciousness, decreased motor activity, selective response to external stimuli
rest= no activity, stress free, feeling refreshed
65
why is sleep important?
affects almost every tissue in the body
regulates metabolism
reduces stress and anxiety
strengthens immune system
66
how much sleep does an adult need?
7-9 hours
67
circadian rhythm
reticular activating system (RAS)
EEG
circadian rhythm: internal clock, 24hr. day/night wake/sleep pattern
reticular activating system (RAS): nerve cells in the brain activating the wake cycle
EEG: sleep/seziure test
68
sleep cycle
NREM 1, NREM 2, NREM 3, NREM 2, REM, NREM 2
69
what is essential for mental resotaration
REM
70
light sleep and slowing brain body and body process are associated with which stage of NREM sleep?
NREM 2
71
when does dreaming occur
REM
72
what stage usually causes vitals to decrease
NREM 3
73
factors affecting sleep
lifestyle, nutrition, medications, environment, illness
74
insomnia
circadian disorders
insomnia: inability to fall or remain asleep
circadian disorders: abnormal sleep/wake times
75
the nurse is caring for a hospitalized client who normally works the night shift at his job. the client states, "I don't know what is wrong with me. I have been napping all day and I can't seem to think clearly." the nurse's best response is:
A. you are sleep deprived, but that will resolve in a few days
B. you are experiencing hypersomnia, so it will be important for you to walk in the hall more often
C. there has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?
D. I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep
C.
76
hypersomnia
excessive sleeping
can be related to depression
77
narcolepsy
chronic disorder cause by the brain's ineffectiveness in regulating sleep-wake cycles normally
78
bruxism
grind/clench teeth
79
for which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care
narcolepsy
80
nursing interventions to promote sleep
avoid interruptions, restful environment, support bedtime rituals, avoid caffeine/tobacco/heavy meals, warm bath, exercise earlier in the evening
81
nutrition
metabolism
standards
food guides
nutrition- how food effects the body and influences health
metabolism- how food is converted to energy
standards- nutrient intake
food guides- tools that be used to educate patients
82
macronutrients
micronutrients
macro- supply energy (carbs, proteins, lipids)
micro- repair and maintain cells (vitamin and minerals)
83
proteins
amino acids, tissue building
84
what does the body burn for energy during exercise
lipids (fats)
85
what does BMR stand for and what does it mean?
basal metabolic rate
amount of energy required at rest
86
what factors can affect BMR
body composition, growth periods, body temp., environment temp., disease
87
identity the client with the greatest risk for developing protein-calorie malnutrition:
A. a client who has multiple sclerosis and is in a wheelchair
B. a client weighing 300 lb who has entered the hospital for cardiac bypass surgery
C. a client with a broken arm and femur from trauma who is running a fever of 101.5 F
D. a client who is of Native American heritage
C.
the client has a fever and experienced trauma
88
BMI calculation
weight (kg) divided by height (m squared)
25 < 29 overweight
30 < obese
less than 18 underweight
89
etiologies (cause) for undernutrition
difficulty swallowing/chewing
alcoholism
vomiting
metabolic disorders
90
what does insulin do for the body
regulates glucose
91
how does glucose arrive in the bloodstream
carbs eaten
glucose that is stored in the body in muscles and liver cells
glucose newly created in the liver or kidney
92
when BG levels are high is more or less insulin secreted by the pancreas
MORE
insulin make glucose decrease
93
what happens in type 1 diabetes
the pancreas quits working, causing a lack of insulin
94
manifestations of type 1 diabetes
polyuria, polydipsia (thirsty), polyphagia (hungry), fatigue, weight loss
95
management of type 1 diabetes
insulin
motoring blood glucose
96
what causes type 2 diabetes
genetics and lifestyle
97
manifestations of type 2 diabetes
3 "Ps", fatigue, poor wound healing, recurring infection
98
management of type 2 diabetes
self interventions (exercise/diet)
99
assessment of herbal supplements
obtain complete list of all medications, including dietary supplements
100
can herbal supplements other prescription/OTC medications
Yes
101
cisgender
gender binary
gender nonbinary
intersex
cisgender- what was assigned at birth
gender binary- 2 genders
gender nonbinary- do not identify
intersex- born with the opposite sex organs
102
what factors affect sexuality
culture, religion, lifestyle, sexual knowledge, health and illness
103
what is sexual orientation
general tendency of a person to feel attracted to another person
104
what are examples of sexual problems
STD/STI, dysmenorrhea, negative intimate relationships, sexual harassment, rape
105
what does the PLISSIT model stand for
permission
limited information
specific suggestions
intensive therapy
106
the 17-year-old client comes to the clinic. she states to the nurse "I think I have an infection in my vagina". after obtaining information on the signs and symptoms, what is the nurse's best response?
A. can you tell me what kind of infection you think you have
B. have you told your mother about your concerns
C. let's discuss your sexual activity
D. do you know how you go this infection
C.
107
in completing an admission history, the nurse learns, that the female client has a female sexual partner. this data speaks to the clients
sexual orientation
108
a physician frequently approaches a nurse and compliments her and her appearance, including making inappropriate comments about the nurse's body shape. what is the most appropriate initial action of the nurse?
inform the physician the behavior is inappropriate and unwelcomed
109
during an initial assessment of the client's sexual orientation, the nurse may utilize the PLISSIT model. what is the first stem of this model?
A. provide information about sexual orientation and common alterations
B. plan time to discuss concerns with the client in a private, comfortable setting
C. permit the client to speak openly by communicating an open, accepting attitude
D. provide referrals to the client so they can identify resources to assist them in the future
C.
110
during a well-checkup visit, a 14-year-old girl asks you if it is okay to masturbate. which statement by the nurse best demonstrates self-knowledge
A. you should not be thinking of sexual activity at your age
B. can you explain what you mean by masturbate
C. you need to discuss sex with your parents because you are a minor
D. this is one way to express sexuality. let's explore your sexual knowledge and sexuality
D.
