Knowledge assessment 2

Question 1

expected results for urinary characteristics

Answer 1

space gravity: 1.005-1.030
pH: 6
Protein: negative
Glucose: absent or low
Ketones: negative
Microscopic analysis: negative for RBC

Question 2

Urinary function testing

Answer 2

ultrasound, KUB study, intravenous pyelography, computed tomography, cytoscopy, contrast medium ice imaging

Question 3

Kidney failure

Answer 3

prerenal: insufficent blood flow,
interrenal: damage to kidney structures such as glomerlus
post renal: obstruction to urine outflow, s/s of decreased urine output, fluid retension, weakness, confusion, fluid electrolyte balances, and cardiac arrhythmias

Question 4

alterations in urinary elimination:

Answer 4

nocturia- urination at night
dysuria- pain while urination
urinary hesitancy- delay in start of urination
urinary frequency- urinating a lot
urinary retention- cannot urinate
incontinence- loss of bladder control

Question 5

types of urinary incontiences

Answer 5

stress
urge
temporary
overflow
functional
mixed

Question 6

Que analysis can be organized by:

Answer 6

disease, physical or psychological barriers to normal elimination, and protentional concerns

Question 7

urinary elimination

Answer 7

kidneys: filter waste products, fluid and electrolyte balances, red blood cell formation, blood pressure regulation, maintains calcium and phosphate levels

Question 8

if the urinary system fails..

Answer 8

all other organs will be affected

Question 9

common urinary problems

Answer 9

urinary retention, UTI, urinary incontience, and urinary diversions

Question 10

factors that can affect urination

Answer 10

developmental considerations, food and fluid intake, sociocultural/pschological variables, actiity and muscle tone, surgical procedures, diagnostic procedures, pathological conditions, pain, and medications

Question 11

infants, children and elderly urination

Answer 11

infants: 15-60mL/kg/day ( no voluntary control
children: cannot control until 18-24 months
elderly: changes in kidney and bladder functions, urgency and frequency increase, elasticty and muscle tone decrease leading to nocturia and incomplete urine elimination

Question 12

What increases and decreases urine output

Answer 12

increase: coffee, tea, alcohol
decrease: foods high in sodium

Question 13

sociocultural and psychological factors of urination

Answer 13

sociocultural: privacy, facillities, proper positioning
psychological: anxiety and stress

Question 14

Surgical procedures affecting urinary system

Answer 14

NPO- anesthetics and narcotic: slow the glomerular filtration rate and impair sensory and motor impulses
- lower abdominal and pelvic area- trauma causes edema and inflammation

Question 15

pathological urination

Answer 15

immobility, communication, cognition in alterations, nuerological conditions, cardiovascular metabolic disorders, bladder/kidney infections, kidney stones, and pain with urination that supresses the urge to void

Question 16

medications that effect urinary

Answer 16

duieretics prevnt reabsrobtion and antichlolinergnic meds cause urinary retention

Question 17

color of urine

Answer 17

Normal- pale
kidney or ureter bleeding- dark red
- bladder or urethra bleeding- bright red
dehydration- dark amber

Question 18

in and out ratios for adults

Answer 18

0.5mL-1mL/kg/hr
normal capacity: 500mL-600mL
normal void- 300mL
urge to void- 150-200mL

Question 19

common test of urinary systems

Answer 19

urinalysis: clean, to the lab within 2 hrs, first void is best midstream
urine culture and sensitvity: sterile and clean void midstream
timed: test renal function and urine composition for 2, 12, or 24 hrs

Question 20

common blood tests for urine

Answer 20

BUN: 7-20mL/dL- elevated levels indicate kidney damage of disease
Creatinine: M: 0.8-1.4mg/dL F 0.6-1.2mg/dL and is byproduct of muscle metabolism. elevated levels indicate kidney damage

Question 21

homeostasis

Answer 21

the bodies ability to maintain that balance. Kidney’s excrete fluid cardiovascular can circulate fluiid if not working well, GI needs to be able to take fluids in

Question 22

water and the human body: functions of water

Answer 22

hydration –> digestion
medium for transporting electrolytes, nutrients, cellular metabolism, chemical functions, maintains body temperature, and is a lubricant for joints

Question 23

potassium, sodium hemoglobin, and BUN for fluid and electrolyte balance

Question 24

Bodily systems: support homeostasis

Answer 24

Thirst – kidneys: controls excerton of fluids – antidieueric hormone: water absorbtion and renin angiotensin aldosterone systems– cardiovascular systems: atrial nutrietic peptide (ANP) and brain natrieutic peptide and lymphatic system helps excessive protein and fluid losses in blood vessels

Question 25

sources of fluid loss and intake

Answer 25

intake sources of water: 1100-1400mL food: 800-1000mL and cell metabolism 300mL I + O measures kidney functions causes: inadequate fluid intake, insensible losses: cannot be measured ( sweat, respiratory, GI tract) and sensible losses ( urine output, wound drainage, gastric drainage)

Question 26

fluid volume excess

Answer 26

Edema, BP goes up, pulse boudning, LOC, dizzinesss, headache, lab findings: BUN, hematocrit, hemoglobin, and urine specific gravity all decrease Causes: over hydration, poor kidney function, heart failure,

Question 27

body water components

Answer 27

intracellular: 40% of our body K+ down extracellular: 20% of our body Na+ down

Question 28

sodium function

Answer 28

balance the amount and distribution of water in our bodies, playing a key role in the control of our blood pressure

Question 29

potassium function

Answer 29

Potassium is a mineral and an electrolyte that your body needs in the proper amount to be able to function its best. It helps your muscles contract, your nerves to function correctly, your heartbeat to stay regular, and certain nutrients get into your cells and waste products to get out.

Question 30

fluid requirement calculation

Answer 30

35-45mL/kg/day ( use 40)

Question 31

basic functions of electrolytes

Answer 31

fluid balance, acid base balance, basic nerve, muscle, heart and brain functions

Question 32

transport of fluid and electrolytes

Answer 32

osmosis: the concentration active transport: energy to move a fluid from one area to the next

Question 33

isotonic

Answer 33

equal in fluid movement from one space to another. fluid is normal saline (0.9) or lactated ringers

Question 34

hypotonic

Answer 34

lower concentration of solids in blood, they move water causing the cell to expand. Fluid is 1/2 normal saline (0.45)

Question 35

Hypertonic

Answer 35

high concentration solids in blood, they move water away causing cell to shrink. fluid is dextrose 10 and 3% normal saline

Question 36

lines of defense

Answer 36

normal pH 7.35-7.45: power of hydrogen in our bodies, a high concentration of hydrogen ions results results in states of acidosis (7.35) low concentration of hydrogen ions results in a state of alkalosis PaO2- 80-100mmHg SaO2 > 95% Co2: 35-45: greater then 45 indication of acidosis, more indicates alkalosis chemical : ingestion of food, respiratory renal, respiratory equated with Co2, renal equated with bicarbonate

Question 37

respiratory alkalosis

Answer 37

Respiratory alkalosis occurs when low carbon dioxide levels disrupt your blood’s acid-base balance. Co2 is down, H+ goes up - from severe anxiety and no not enough o2

Question 38

respiratory acidosis

Answer 38

Respiratory acidosis is when your lungs can’t remove enough carbon dioxide from your body. Co2 is up, H+ is down -symptoms include anxiety, fatigue and memory loss. Could be a sign to a respiratory infection

Question 39

metabolic alkalosis

Answer 39

In metabolic alkalosis there is excess of bicarbonate in the body fluids and hydrogen is down. It can occur in a variety of conditions. - vomiting

Question 40

metabolic acidosis

Answer 40

Metabolic acidosis can develop if you have too many acids in your blood that wipe out bicarbonate and an increase in H+ - ketoacidosis - excessive alc intake

Question 41

shear

Answer 41

a gravity force pushing down on the patients body with resistance between the patient and the chair or bed

Question 42

why bed rest

Answer 42

reduces oxygen needs decreases pain level helps in regaining of strength uninterupted rest has psychological and emotional benefits

Question 43

immobility may be

Answer 43

temporary, such as following a surgery for a total knee replacement permanent, such as paraplegia sudden onset- such as a fractured arm and leg slow onset- such as multiple sclerosis

Question 44

metabolic changes

Answer 44

changes in mobility alter endocrine metabolism calcium resorption functioning of the GI system - endocrine system helps maintain homeostasis immobility disrupts normal metabolic functioning decreases metabolic rate alters metabolism causes GI disturbances

Question 45

Endocrine system helps maintain homeostasis

Answer 45

decreases in BMR which causes - altered metabolism of carbohydrates, fats, and proteins which causes - fluid, electrolytes and calcium imbalances which causes - GI disturbances which causes - decrease in appetite and decrease in peristalsis

Question 46

nutrition and metabolism: assessment

Answer 46

height, weight, skin folds fluid intake and output measurements lab test for electrolytes imbalances /nutritional status assess alibity to heal and fight infection assess urinary and bowel elimination status ascultate bowel sounds

Question 47

nursing intervention: nutrional metabolism

Answer 47

provide a high calorie and high protein supplemental B and C monitor and evaluate I & O assess food intake

Question 48

effects of immobility on the respiratory system

Answer 48

decreased respiratory movement resulting in decreased exchange pooling (stasis) of secretions decreased and weakened respiratory muscles resulting in atelectasis and hypostatic pneumonia decreased cough response

Question 49

respiratory system assessment

Answer 49

observe chest movement auscultate fro pulmonary secretions check 02 saturation observe for respiratory difficulties

Question 50

nursing assesment: respiratory system

Answer 50

maintain a patent airway - assess the client ability to expectorate secretion - assess secretions for color, amount, and consistency - use suction if the client is unable to expectorate secretion

Question 51

nursing interventions: respiratory systems

Answer 51

repositions every 1-2 hrs each client to turn, cough, and deep breath yawn every hour use incentive spirometer implement chest physiotherapy consume 2000mL

Question 52

effects of immobility of cardiovascular system

Answer 52

orthostatic hypotension increased cardiac workload BUT decreases cardiac output leading to poor cardiac effectiveness - increases oxygen requirement - less fluid volume in circulatory system - stasis of blood in the legs - thrombus formation - most dangerous complication in immobility

Question 53

cardiovascular system: assessment

Answer 53

BP measurement with postural changes monitor pulse monitor for edema increase activity as soon as possible dangling feet before standing

Question 54

nursing interventions: cardiovascular system

Answer 54

prevent venous stasis - anti embolic stockings never massage extremities - observe for S&S deep vein thrombosis - compression devices - avoid placing pillows under knees or lower extremities, crossing the legs or sitting for long

Question 55

nursing interventions for cardiovascular

Answer 55

increase acttivity as soon as possible chnage position as often as possible perform isometric exercises to increase activity tolerance ROM increase fluid intake give low dose heparin

Question 56

mobility assessment

Answer 56

gait, exercise, activity tolerance, physiological, emotional, developmental Body allignment: identifies deviations, posture, trauma, muscle damage, or nerve function

Question 57

ROM

Answer 57

contractures: develop in joints not moved periodically through their full ROM - neck, shoulders, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle, foot, and toes

Question 58

effects of mobility on elimination

Answer 58

urinary stasis, UTI's - decreased fluid intake, poor perineal care, indwelling catheters renal calculi- chnage in calcium metabolism with hypercalcemia resulting in renal calculi constipation fecal impaction

Question 59

interventions of elimination

Answer 59

force fluids, record I + O, provide perineal care - insert catheter of bladder is distended

Question 60

nursing interventions for GI

Answer 60

asses bowel sounds, hydration, record BM, add fruit veg and fiber to diet, give stool softener, remove fecal impactions

Question 61

effects of immobility on the integumentary system

Answer 61

pressure ulcers, inflammation, ischemia higher risk in older adults: break in skin is difficult to heal, can lead to more immobilization

Question 62

integumentary assessment

Answer 62

nutritional status, assess positions and the risk with each position, identify clients at risk, observe for skin breakdown

Question 63

integumentary interventions

Answer 63

identify clients as risk, assess nutritional status, daily skin exam, provide daily skin and perineal care, turn patient every 1-2 hrs, use support devices, teach client how to shift weight, increase proteins, calories, and vitamins

Question 64

effects of immobility psychosocial issues

Answer 64

hostility, giddiness, fear, anxiety, altered sleep patterns, frequent dozing disrupts nighttime sleep patterns, sleep in an unfamiliar, nosy place, depression, difficulty understanding directions, crying, confusion

Question 65

psychosocial assessment

Answer 65

knowledge of exercise or activity, readiness to change behavior, program customized to meet personalized needs, culture and ethics, family support

Question 66

psychosocial nursing interventions

Answer 66

socialization, meaningful stimuli, maintain body image, avoid sleep interruptions, remain oreinted time, person, place, semi private room with alert roommate, involve client in daily care, daily stimuli

Question 67

reception

Answer 67

stimulation to. a single nerve cell of group of cells to create an impulse sen to the brain

Question 68

perception

Answer 68

brain interprets the stimuli based on past experiences or newness

Question 69

reaction/response

Answer 69

only the most important stimuli will elicit a reaction - intensity, contrast, adaptation, and previous experience

Question 70

stimuli

Answer 70

infants need stimuli to grow, adults reduce their stimuli with age

Question 71

decrease of senses with age

Answer 71

30-hearing 40- visual 50- smell, taste 60 - balance, coordination

Question 72

culture for senses

Answer 72

differeing amounts of eye contact, persoonal space, and touch family presence- may perfer have family or be alone vision and hearing deficits impact health literacy and understanding

Question 73

sensory deficit

Answer 73

deficit in the normal functioning of sensory reception and perception

Question 74

sensory deprivation

Answer 74

inadequate quantity or quality of stimulation

Question 75

sensory overload

Answer 75

recpetion of multiple sensory stimuli

Question 76

interventions for sensory

Answer 76

frequent orientation, encourage visitors, organize care, quiet times, dim lights at night, avoid excessive conversation outside the room, cannot turn off alarms

Question 77

vision assessment

Answer 77

squinting, blurred vision, glasses, difficulty distinguishing colors, difficulty reading, decreased ability for ADL's. decreased socialization, falls

Question 78

implementing vision

Answer 78

good lighting, good eye contact, large print, decrease glare, sunglasses, color contrast

Question 79

driving safe tips for blurred vision

Answer 79

drive in familiar areas, no night driving, avoid highways, have a phone with you, drive slow, keep car in good repair

Question 80

assesment for presbycusis (hearing loss)

Answer 80

patient asks you to repeat yourself, inattentive, has a hearing aid, responds inappropriately, speaks too loud of too soft, doesnt follow directions, turn shead one direction, smiles and nods

Question 81

implementation for hearing loss

Answer 81

ask about hearing aids talk slow and clear get pateints attention speak to good ear sign language, lip reading, pad pad and pencil, quiet environment, amplified phone, move to personal space.

Question 82

assessment for smell and taste

Answer 82

increased bod odor, weight change, appetite change, excess use of seasonings or sugar,

Question 83

implenmentation for smell and taste losses

Answer 83

oral hygiene, good hydration, seasonings, remove unpleasant odors, no blending or mixing foods, different textures, check expiration dates

Question 84

touch assesment

Answer 84

clumsiness, failure to respond to touch, numbness, tingling, decreased grip, over or under reaction to pain

Question 85

touch implementation

Answer 85

massage, check temperature, firm, label faucets, be careful with hot and cold items, no heating pads, loosen linens on bed, check skin

Question 86

special communication needs

Answer 86

use pictures, paper, no shouting, be patient, vibrator voice box

Question 87

aphasia

Answer 87

inability to speak, intrepret, or understand langauge

Question 88

expressive aphasia

Answer 88

inability to name common objects or express simple ideas in words or writing bonica

Question 89

sensory or receptive aphasia

Answer 89

inability to understand written or spoken langauge - wernicke

Question 90

sensory implementation in community

Answer 90

vision and hearing screenings home risk assessment alternative communication use of assistive devices

Question 91

home risk assesment

Answer 91

cracked sidewalks, scatter rugs, extension cords, clutter, labeled faucets, lighting, grab bars

Question 92

delirium vs dementia

Answer 92

delirium is a period of confusion, can be reversed dementia is forever

Question 93

interventions for confused patients

Answer 93

promote orientation, do not offer too many choices, face patient while speaking, relieve anxiety