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Nursing Process > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

Most common cause of injury fatality from falls

A

Age > 65

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2
Q

Assessment for fall risk in older adults

A 
DAME:
D- drug and alcohol abuse
A- age related physiologic status
M- medical problems
E- environment
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3
Q

How long is a restraint order valid?

A

24 hours

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4
Q

How often should you reassess the need for restraints?

A

Adult: q4h
child > 9: q2h
child

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5
Q

How often should you assess a patient with restraints?

A

adult: every hour

child

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6
Q

5 Ps

A 
Pain
Pallor
Potty
Pulse
Position
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7
Q

When is a psych consult needed for a patient who is restrained?

A

After 48 hours of retraints

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8
Q

factitious disorder

A

clients deliberately make up or inflict symptoms

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9
Q

example of factitious disorder

A

Muchausen by proxy: parents or caregivers exaggerate or fabricate illness or symptoms for their child to gain attention

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10
Q

somatoform disorder

A

clients experience physcial symptoms despite no underlying medical explanation

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11
Q

primary and secondary gains of somatoform disorders

A
  • primary: symptoms block psychological conflict or anxiety from conscious awareness
  • secondary: relieves clients from expected responsibilities and increases the attention they receive
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12
Q

treatment of somatoform disorder

A

antidepressants and don’t focus on the symptoms

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13
Q

daily carbs

A

10-100 g/day

45-65% of daily needs

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14
Q

average carbs in a large apple

A

31 g

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15
Q

daily protein

A

0.8 g/kg/day

10-35% of daily needs

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16
Q

complete vs incomplete protein sources

A
  • complete: animal products

- incomplete: plants

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17
Q

daily fats

A
  • No RDA

- 20-35% of daily needs

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18
Q

Vitamin A

A
  • vision
  • formation and maintenance of skin and mucus membranes
  • immune function
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19
Q

vitamin B1

A

thiamin- produces energy from glucose

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20
Q

vitamin B2

A

riboflavin- carb, protein, and fat metabolism

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21
Q

vitamin B3

A

niacin- carb, protein, and fat metabolism

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22
Q

B6

A

pyridoxine- coenzyme in metabolism

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23
Q

folate

A

RNA/DNA synthesis, form/mature RBCs

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24
Q

vitamin B12

A

protein metabolism and formation of heme

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25
Q

pantothenic acid

A

carb, protein, and fat metabolism

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26
Q

biotin

A

carb, protein, and fat metabolism

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27
Q

vitamin C

A

ascorbic acid- collagen formation, antioxidant, enhance iron absorption

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28
Q

vitamin D

A

cholecalciferol- Ca+ and phos metabolism, stimualte Ca+ absorbsion

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29
Q

vitamin E

A

tocopherol- antioxidant, heme synthesis, protects vit A

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30
Q

vitamin K

A

blood clotting!

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31
Q

my plate

A

half the plate should be fruits and veg, 1/4 protein, 1/4 grains; half the grains should be whole grains; fat free or low fat milk

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32
Q

primary vs secondary obesity

A

secondary occurs because of health complications

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33
Q

ideal body weight

A
  • females: 100lb +/- 5 lbs for each additional inch over 5ft
  • males: 106lb +/- 6lb for each additional inch over 5ft
  • add or deduct 10% for frame
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34
Q

BMI calculations

A
  • Wt in kg/ (ht in meters) x (ht in meters) OR

- Wt in lbs/ (ht in inches) x (ht in inches) x 703

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35
Q

overweight BMI

A

25-29.9

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36
Q

obese BMI

A

> 30

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37
Q

extreme obesity BMI

A

> 40

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38
Q

normal weight BMI

A

18.5-24.9

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39
Q

restraint documentation

A
  • Date and time restraint applied
  • Type
  • Alternatives attempted
  • Notification of family
  • Frequency of assessment
  • Findings
  • Regular intervals when restraint removed
  • Nursing interventions
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40
Q

underweight BMI

A
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41
Q

1 lb is equal to how many calories?

A

3500

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42
Q

dietary treatment of obesity

A
  • includes behavior modification and exercise

- diary over 7 days is better than 1 day because anyone can change their diet for a day

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43
Q

drug therapy for obesity

A
  • drugs that reduce food intake by reducing appetite or satiety
  • drugs that increase energy expenditure
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44
Q

bariatric surgery

A
  • must have BMI >40
  • Have to have been obese for >5 years
  • Has tried and failed to lose weight
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45
Q

life expectancy for anorexic

A

35 years because of heart failure

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46
Q

major diagnostic findings with malnutrition

A

low serum albumin (but albumin also lowers with age)

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47
Q

consistent-cho diet

A

diabetes, glucose intolerance

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48
Q

fat-restricted diet

A

chronic cholecystitis, cardiovascular disease

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49
Q

high fiber diet

A

prevent or treat constipation, IBS, diverticulosis

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50
Q

low fiber diet

A
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51
Q

Na+ restricted diet

A

HTN, HF, acute/chronic renal disease, liver disease

-500-3000 mg/day

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52
Q

clear liquid diet

A
  • prep for surgery or endoscopy

- becomes clear with body temp

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53
Q

full liquid diet

A

made up of liquids and foods that turn to liquid at room temp (like ice cream)

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54
Q

time limit for NPO pts

A

3 days

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55
Q

how often should you flush an NG tube

A

q4h

56
Q

tracheoesophageal fistula

A

congenital; failure of the esophagus to develop as a continuous passage and failure of the trachea and esopagus to separate into distinct structures

57
Q

clinical manifestations of trachoesophageal fistula

A

excessive frothy mucus from the nose and mouth, coughing, choking, cyanosis, apnea; increase resp distress during feeding; abdominal distension

58
Q

hypertrophic pyloric stenosis

A

projectile vomiting, nonbillus (bc it doesn’t leave the stomach), fully obstructed

59
Q

cleft palate

A

bi-uvula so it looks like a W

60
Q

repair of cleft lip/palate

A

lip precedes palate (bc baby needs to feed); lip at 2-3 months; palate at 6-12 months

61
Q

Diagnostic criteria for abdominal pain

A

Rome III- complete family Hx, childs health Hx, physical exam, lab test

62
Q

fluid maintenance in children

A
  • allow 100 ml/kg for first 10 kg body wt
  • allow 50 ml/kg for second 10 kg body wt
  • allow 20 ml/kg for remaining kg body wt
63
Q

If meconium is not passed within 24-36 hours…

A

Hirschsprung disease, hypothyroidism, meconium plug/ meconium ileus (CF)

64
Q

Hirschsprung disease

A

congenital ganglionic megacolon- mechanical obstruction from inadequate motility of the intestine from absense of ganglion cells in colon
-could lead to entercolitis

65
Q

Tx of constipation in infant

A

sucrose or corn syrup

66
Q

most intense site of pain in appendicitis

A

Mcburney point

67
Q

meckel diverticulum

A

fibrous band connecting small intestin to umbilicus

68
Q

symptoms of meckel diverticulum

A

painless rectal bleeding, currant jelly stool or dark red, can cause HTN bc of huge blood loss

69
Q

Dx and Tx of meckel diverticulum

A

Dx- radiograph

Tx- sugery

70
Q

cluster A personality disorders

A

odd or eccentric behavior is core characteristic

  • “schizophrenic spectrum cluster”
  • odd, withdrawn, suspicious, and irrational
71
Q

paranoid personality disorder

A
  • cluster A
  • suspicious and quick to take offense
  • project feelings
  • few friends, looks for hidden meaning in innocent remarks, guarded
  • quick to react with anger
  • do not lose touch with reality
72
Q

goal of therapy for paranoid personality disorder

A

solve immediate crisis or problem

73
Q

schizoid personality disorder

A
  • cluster A
  • “lifelong loner”
  • show indifference to relationships, flat affect, cold, unsociable
  • usually never marry, little interest in sexuality
  • solitary jobs that others would hate
  • more common in men than women
74
Q

goal of treatment for schizoid

A

solve immediate crisis or problem

75
Q

schizotypal personality disorder

A
  • cluster A
  • extreme discomfort with and intolerance for close relationships
  • thought patters are disturbed, with odd behavior, speech and appearance
  • inappropriate/ constricted affect
  • no friends
  • social anxiety
76
Q

goal of treatment for schizotypal

A

complete social skills training

77
Q

cluster B personality disorders

A

dramatic, emotional, erratic manifestations

  • moods are labile and shallow
  • involved in intense interpersonal conflicts
78
Q

antisocial personality disorder

A
  • cluster b
  • aggression and irrisponsibility lead to conflicts with society and criminal justice
  • fighting, lying, stealing, domestic violence, substance abuse
  • lack genuine warmth
  • more common in men
79
Q

goal of therapy for antisocial personality disorder

A
  • improve social relationships

- enhance insight into antisocial feelings and behaviors

80
Q

borderline personality disorder

A
  • cluster b
  • instability in mood, impulse control, and interpersonal relationships
  • unpredictable and erratic
  • splitting- view things as extreme: all good or all bad
  • assume little responsibility for their own problems
  • enraged if they think they’re being ignored
81
Q

treatment goals for borderline

A
  • prevent suicide

- function independently, maintain emotional balance, and engage in cognitive restructuring

82
Q

histrionic personality disorder

A
  • cluster b
  • excessive emotionality and attention seeking
  • want to be the center of attention (focus on self, provocative dress, highly emotional displays)
  • seductive behaviors to gain approval
  • inconsistent and unpredictable
83
Q

treatment goals for histrionic personality disorder

A
  • prevent suicide

- gain insight into unrealistic expectations and fears

84
Q

narcissistic personality disorder

A
  • cluster b
  • self-centeredness, self-absorption, inability to empathize with others, grandiosity, and extreme desire for admiration
  • self esteem is till fragile
  • haughty arrogant, capable of taking advantage of others to achieve their own ends
85
Q

treatment goal for narcissistic personality disorder

A
  • develop a healthier sense of individuality
  • recognize others as separate people
  • improve coping mechanisms
86
Q

cluster C personality disorders

A

marked by anxious or fearful behaviors

  • anxious, tense, and overcontrolled
  • differentiation is difficult
87
Q

avoidant personality disorder

A
  • cluster C
  • social discomfort, timidity, fear of negative evaluation
  • preoccupied with their perceived shortcomings
  • reluctant to take risks or try new activities for fear of embarrassment, shame, or ridicule
88
Q

treatment goals for avoidant personality disorder

A
  • enhance social functioning

- solve immediate crisis or problem

89
Q

dependent personality disorder

A
  • cluster C
  • Pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fear of separation
  • Need much approval from others that they have trouble making independent decisions
  • May go to great lengths to stay in a relationship
  • Become extremely anxious if placed in a position of authority
90
Q

treatment goals for dependent personality disorder

A
  • Complete assertiveness training

- Engage in cognitive restructuring

91
Q

obsessive compulsive disorder

A
  • perfectionism, rigidity, controlling behavior, and extreme orderliness
  • traits exist as an expense of efficiency, flexibility, and candor
  • Results in indecisiveness, preoccupation with detail, and an insistence that other do things their way
92
Q

treatment goal for OCD

A

-experience specific symptom relief

93
Q

Most common ER occurrence for eating disorders

A

anorexia for v-tach

-treatment would be fluid intake, electrolytes and labs

94
Q

prevalence of eating disorders in the US

A

1-4% of population

95
Q

ratio of men to women for anorexia and bulimia

A

anorexia 2:1

bulimia 3:1

96
Q

manifestations of anorexia

A
  • typically weigh less than 85% of normal for ht and age
  • distorted body image
  • may have amenorrhea, lanugo hair, hypotension, bradycardia, hypothermia, constipation, polyuria, and electrolyte imbalances
97
Q

assessment priorities for eating disorders

A

do not weigh them, but look at their fluid intake and electrolytes

98
Q

bipolar I vs bipolar II

A

I includes manic episodes, II is depressive with hypomanic episodes (less severe than manic)

99
Q

best therapy for treating depression

A

cognitive behavioral therapy

100
Q

tricyclic antidepressants

A

block reuptake of norepinephrine and serotonin

-narrow therapeutic index

101
Q

lithium indications and diet

A

mood stabilizer for bipolar

-diet: 2000-3000 ml fluid/day and eat consistent and moderate intake of Na+, avoid diuretics

102
Q

prozac pt teaching and nursing considerations

A
  • don’t take with MAOIs
  • takes 4-6 wks to work
  • highest risk for suicide is in the first 14 days so monitor them in that time frame
103
Q

lamictal indications and teaching

A
  • anticonvulsant used for bipolar
  • do not stop drug abruptly- could cause seizures
  • could increase suicidal thoughts
  • non hormonal contraception
104
Q

warnings for suicide risk

A 
IS PATH WARM
Ideation
Substance abuse
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal 
Anger
Recklessness
Mood change
105
Q

suicide risk assessment

A 
SAD PERSONS
Sex: women attempt more, men succeed more
Age: white males > 85
Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social support lacking
Organized plan
No spouse
Sickness
106
Q

depersonalization disorder

A

belief that one’s own reality is temporarily lost or altered

  • dissociation occurs
  • usually rapid onset and occurs in adolescence under extreme stress, fatigue, or anxiety
107
Q

newborn urinary defect

A

bladder exstrophy: midline closure defect that occurs during embryonic period, leaving the bladder open and exposed outside of the abdomen

108
Q

acute glomerulonephritis

-age, etiology, manifestations

A
  • school aged children
  • inflammation of the glomeruli and onset of hematuria, proteinuria, HTN, azotemia, bacteriuria
  • usually caused by strep
109
Q

management of acute glomerulonephritis

A

-fluid and Na+ restrictions
K+ restrictions with oliguria
-BP, I&O, weight
-management of HTN

110
Q

Normal WBC and specific gravity in urinalysis for children

A

-WBC

111
Q

high specific gravity vs low

A

high- dehydration

low- excessive fluid intake

112
Q

Nephrotic syndrome

A

group of symptoms including presence of proteinuria, low serum albumin, and edema

113
Q

manifestations of nephrotic syndrome

A

NAPHROTIC

Na+ decrease
Albumin decrease
Proteinuria >3.5 g/day
Hyperlipidemia
Renal vein thrombosis
Orbital edema
Thromboembolism
Infection
Coagulability
114
Q

Therapy for nephrotic syndrome

A

corticosteroids

115
Q

Prep for IVP (intravenous pylogram)

A

-2 yrs: catharsis, NPO, enema in the morning

116
Q

vescicoureteral reflex

A

backflow of urine from the bladder into the ureters, which can cause bacteria to grow
-grades 1-5, 5 being the worst

117
Q

goal of and treatment for cescicoureteral reflex

A
  • goal: prevent infection

- treatment: prophylactic antibiotic qd

118
Q

phimosis

-normal vs abnormal

A

a narrowing or stenosis of the preputial opening of the foreskin that prevents retraction of the foreskin over the glans penis

  • normal for infnats and young boys but usually disappears
  • occasionally narrowing obstructs urine flow
  • newborns with this should not be circumcised until repaired
119
Q

most common cause of acute renal failure

A

dehydration

120
Q

principle feature/manifestation of acute renal failure in children

A

oliguria

121
Q

management of acute renal failure in children

A
  • treat underlying cause
  • monitor I&O
  • promote active and normal lifestyle
122
Q

treatment of acute renal failure in adults

A
  • treat precipitating cause
  • diuretics
  • decrease serum K+ (Kayexalate, Sorbitol, IV hypertonic glucose and regular insulin if severe hyperkalemia)
  • IV sodium bicarb
  • IV dopamine to enhance renal perfusion
123
Q

diet for acute renal failure

A
  • fluid restriction (strict I&O)
  • regulate intake of Na+ and K+
  • increase intake of carbs and protein
124
Q

when should dialysis be done for ARF

A
  • volume overload
  • BUN> 120mg/dl
  • metabolic acidosis with hyperkalemia
  • ECG changes, cardiac tamponade
125
Q

daily weight during oliguric phase of ARF

A

0.2-0.3 kg/day loss

126
Q

meds for chronic renal failure

A
  • decrease K+
  • antiHTN
  • thiazide and loop diuretics
  • erythropoietin for anemia tx
  • phos binders and vit D for renal osteodystrophy
127
Q

diet for chronic renal failure

A
  • restrict protein intake to 20-40 g/day
  • fluid restriction- 600 to 1000 mL/day
  • Na+ and K+ restrictions
128
Q

nursing considerations in hemodialysis access devices

A

NEVER take BP, blood draws, or unfuse fluids or meds into the access site or the extremity

129
Q

most common side effects of hemodialysis

A

hypotension, headache, muscle cramps, bleeding from access site

130
Q

complications of hemodialysis

A
  • Dialysis disequilibrium syndrome: cerebral edema and neurologic complications (HA, N/V, Sz) may be minimized by slower dialysis
  • Sepsis, Hepatitis B and C
131
Q

medications during hemodialysis

A

hold CV meds prior to dialysis

132
Q

complications of peritoneal dialysis

A
  • Possible bowel perforation from catheter insertion

- Peritonitis, bleeding, hypoalbuminemia, hyperglycemia in DM patients

133
Q

positive vs negative symptoms of schizophrenia

A
  • positive- hallucinations and delusions (most noticeable)

- negative- isolation and detachment… go unnoticed for a long time; precursor to diagnosis

134
Q

med for alcohol and opioid withdrawal

A

both: naltrexone
alcohol: disulfiram (antabuse) causes unpleasant reactions to alcohol

135
Q

most commonly abused psych drug

A

benzos

Nursing Process (4 decks)

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