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Nur 103 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

what is the #1 factor affecting skin integrity?

A

impaired circulation

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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.

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3
Q

Acute wound
chronic wound

A

acute= new
chronic= ongoing

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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)

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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

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6
Q

hemorrhage

A

forms in 24-48hrs.
swelling, pain, and vital changes may occur

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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)

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8
Q

wound care

A

cleansing/irrigating
debriding
changing the dressing
heat/cold

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9
Q

how are pressure injuries caused

A

unrelieved pressure to an area, resulting in ischemia

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10
Q

pressure injury intrinsic factors

A

immobility, impaired sensation, poor nutrition, dehydration, aging, fever/infection, edema

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11
Q

pressure injury extrinsic factors

A

friction, pressure, shearing, moisture

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12
Q

how many stages are there of a pressure injury?

A

4 stages
DTI
unstageable

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13
Q

stage 1 of a pressure injury

A

discoloration will remain for more than 30 minutes after pressure is relieved

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14
Q

stage 2 of a pressure injury

A

partial-thickness loss of skin (epidermis)
wound bed is visable

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15
Q

stage 3 of a pressure injury

A

full-thickness loss (adipose is visible)
tunneling may occur

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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

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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)

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18
Q

unstageable pressure injury

A

full-thickness loss
unsure of the extent of injury from slough and eschar

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19
Q

which patient are checked for risk assessment

A

ALL patients

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20
Q

when are reassessments done?

A

every 24hr- minimum
every 12hr- best practice

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21
Q

when are skin reassessments done?

A

every 8-24 hours

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22
Q

Braden score

A

6-23
lower the score the higher the risk

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23
Q

skin with too little moisture is how many times likely to ulcerate

A

2.5

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24
Q

skin with too much moisture is how many times likely to ulcerate

A

5

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25
Q

how high should the HOB be?

A

<30

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26
Q

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

A

B.
it is important the patient is out of pain before wound care is done

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27
Q

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

A

C.
you want to reposition the patient first

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28
Q

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

A

D.

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29
Q

when assessing a wound, what do you all check?

A

location
size (in cm)
appearance
drainage
redness
swelling

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30
Q

where do wounds heal faster?

A

stabilized areas

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31
Q

what color is eschar and where is it located

A

tan, brown, black
on wound bed

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32
Q

what color is slough and where is it located

A

yellow, tan, brown, green, grey
in the wound bed

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33
Q

what is granulation tisse?

A

deep pink or red, moist, glistens on irregular granular surface

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34
Q

what documented for peri-wound skin and wound edges

A

pain
edema
induration (hardness)
erythema (redness)
maceration (white-wet)

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35
Q

what is:
abrasion
laceration

A

abrasion= wearing away of the upper layer of skin as a result of applied friction
laceration= deep cut or tear into the skin

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36
Q

what is ecchymosis

A

reddish to bluish discoloration of the skin, from the rupture of blood capillaries beneath the skin

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37
Q

what is a hematoma

A

swelling filled with blood, from a break in a blood vessel

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38
Q

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

A

B.
the nurse needs to sterilize the wound first to see if it prevents the wound to get worst

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39
Q

T.A.C.O

A

type
amount
consistency
odor

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40
Q

serous exudate
sanguineous
serosanguineous
purulent
purosanguineous exudate

A

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

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41
Q

scant

A

wound is moist, no visible drainage

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42
Q

low viscoisty=

A

thin, runny

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43
Q

what is the normal urine output
per day
per hour

A

per day= 1500mL
per hour= 40-60 mL

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44
Q

where are nephrons located and what do they do

A

located in the kidney, serve as a filter

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45
Q

what do ureters do

A

transport urine from the kidneys to the bladder

46
Q

what does the bladder do

A

holds urine

47
Q

what does the urethra do
who has a longer urethra? men or women

A

excretes urine from the bladder
men have a longer urethra (8 inches)
women (1.5-2.5 inches)

48
Q

factors affecting urinary elimination

A

personal, religion, environment, nutrition, activity, medication

49
Q

pathological conditions affecting urinary elimination

A

kidney infection, kidney stones, prostate (male), neurological condition

50
Q

nocturia
polyuria
oliguria
anuria
dysuria
diuresis
enuresis

A

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
Q

pyuria
pyelonephritis
cystitis

A

pyuria- pus in urine
pyelonephritis- infection spread to upper kidneys
cystitis- bladder infection

52
Q

medical alterations in urinary elimination

A

UTI, urinary retention, urinary incontinence, urinary diversion

53
Q

what is usually done to manage urinary retention

A

catheterization

54
Q

nursing intervention for managing urinary incontinence

A

toileting schedule (bladder training), kegel exercises, anti-incontinence devices

55
Q

urine assessment

A

color, clarity, odor, amount

56
Q

small intestine

A

aids in digestion and absorption
turns food into chyme
divided into 3 sections (D, J, I)

57
Q

large intestine

A

the cecum, ascending colon, transverse colon, descending colon, sigmoid, rectum, anus

58
Q

what are factors affecting bowel elimination

A

developmental stage, personal factors, nutrition, medications, pregnancy, ileostomy, colostomy

59
Q

bowel function assessment

A

elimination pattern, routine, appetite, nutrition, surgery, medications, mobility

60
Q

stool assessment

A

meds, color, consistency, amount

61
Q

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

A

B.
if one specimen is accidentally disposed, you have to start over

62
Q

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?

A

assess
palpate
bladder scan

63
Q

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

A.

64
Q

Sleep vs Rest

A

sleep= altered consciousness, decreased motor activity, selective response to external stimuli
rest= no activity, stress free, feeling refreshed

65
Q

why is sleep important?

A

affects almost every tissue in the body
regulates metabolism
reduces stress and anxiety
strengthens immune system

66
Q

how much sleep does an adult need?

A

7-9 hours

67
Q

circadian rhythm
reticular activating system (RAS)
EEG

A

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
Q

sleep cycle

A

NREM 1, NREM 2, NREM 3, NREM 2, REM, NREM 2

69
Q

what is essential for mental resotaration

A

REM

70
Q

light sleep and slowing brain body and body process are associated with which stage of NREM sleep?

A

NREM 2

71
Q

when does dreaming occur

A

REM

72
Q

what stage usually causes vitals to decrease

A

NREM 3

73
Q

factors affecting sleep

A

lifestyle, nutrition, medications, environment, illness

74
Q

insomnia
circadian disorders

A

insomnia: inability to fall or remain asleep
circadian disorders: abnormal sleep/wake times

75
Q

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

A

C.

76
Q

hypersomnia

A

excessive sleeping
can be related to depression

77
Q

narcolepsy

A

chronic disorder cause by the brain’s ineffectiveness in regulating sleep-wake cycles normally

78
Q

bruxism

A

grind/clench teeth

79
Q

for which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care

A

narcolepsy

80
Q

nursing interventions to promote sleep

A

avoid interruptions, restful environment, support bedtime rituals, avoid caffeine/tobacco/heavy meals, warm bath, exercise earlier in the evening

81
Q

nutrition
metabolism
standards
food guides

A

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
Q

macronutrients
micronutrients

A

macro- supply energy (carbs, proteins, lipids)
micro- repair and maintain cells (vitamin and minerals)

83
Q

proteins

A

amino acids, tissue building

84
Q

what does the body burn for energy during exercise

A

lipids (fats)

85
Q

what does BMR stand for and what does it mean?

A

basal metabolic rate
amount of energy required at rest

86
Q

what factors can affect BMR

A

body composition, growth periods, body temp., environment temp., disease

87
Q

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

A

C.
the client has a fever and experienced trauma

88
Q

BMI calculation

A

weight (kg) divided by height (m squared)
25 < 29 overweight
30 < obese
less than 18 underweight

89
Q

etiologies (cause) for undernutrition

A

difficulty swallowing/chewing
alcoholism
vomiting
metabolic disorders

90
Q

what does insulin do for the body

A

regulates glucose

91
Q

how does glucose arrive in the bloodstream

A

carbs eaten
glucose that is stored in the body in muscles and liver cells
glucose newly created in the liver or kidney

92
Q

when BG levels are high is more or less insulin secreted by the pancreas

A

MORE
insulin make glucose decrease

93
Q

what happens in type 1 diabetes

A

the pancreas quits working, causing a lack of insulin

94
Q

manifestations of type 1 diabetes

A

polyuria, polydipsia (thirsty), polyphagia (hungry), fatigue, weight loss

95
Q

management of type 1 diabetes

A

insulin
motoring blood glucose

96
Q

what causes type 2 diabetes

A

genetics and lifestyle

97
Q

manifestations of type 2 diabetes

A

3 “Ps”, fatigue, poor wound healing, recurring infection

98
Q

management of type 2 diabetes

A

self interventions (exercise/diet)

99
Q

assessment of herbal supplements

A

obtain complete list of all medications, including dietary supplements

100
Q

can herbal supplements other prescription/OTC medications

A

Yes

101
Q

cisgender
gender binary
gender nonbinary
intersex

A

cisgender- what was assigned at birth
gender binary- 2 genders
gender nonbinary- do not identify
intersex- born with the opposite sex organs

102
Q

what factors affect sexuality

A

culture, religion, lifestyle, sexual knowledge, health and illness

103
Q

what is sexual orientation

A

general tendency of a person to feel attracted to another person

104
Q

what are examples of sexual problems

A

STD/STI, dysmenorrhea, negative intimate relationships, sexual harassment, rape

105
Q

what does the PLISSIT model stand for

A

permission
limited information
specific suggestions
intensive therapy

106
Q

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

A

C.

107
Q

in completing an admission history, the nurse learns, that the female client has a female sexual partner. this data speaks to the clients

A

sexual orientation

108
Q

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?

A

inform the physician the behavior is inappropriate and unwelcomed

109
Q

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

A

C.

110
Q

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

A

D.

Nur 103 (4 decks)

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