Exam 4 Study Guide: Q Flashcards
WHICH DIAGNOSTIC TEST/EXAM WOULD BEST MEASURE A CLIENT’S LEVEL OF HYPOXEMIA?
CHEST X-RAY
PULSE OXIMETER READING
ARTERIAL BLOOD GAS (ABG) SAMPLING
PEAK EXPIRATORY FLOW RATE
Arterial Blood Gas (ABG) Sampling
- exchange of o2 and co2
- takes place inside of the lungs
Respiration
- movement of air in and out of lungs
- what is counted when getting RR
Ventilation
T or F:
the term “Kussmaul” refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the library
False:
- the term for this sound of respiratory distress is “stridor”
- Kussmaul respirations are slow and deep, seen in DKA
- slow and deep
- seen in DKA
Kussmaul Breathing Patterns
- high-pitched
- harsh
- crowing inspiratory sound that occurs due to partial obstruction of t he larynx
Stridor
gradual increase in depth and respiration followed by decrease in depth and respiration and then apnea
Cheyne Stokes
what conditions are associated with the sputum color:
white/clear
viral
- usually with common cold
what conditions are associated with the sputum color:
yellow/green
bacterial
what conditions are associated with the sputum color:
black
smoke or dust inhalation
what conditions are associated with the sputum color:
rust
- pneumonia
- TB
- Blood: hemoptysis
coughing up blood
hemoptysis
what conditions are associated with the sputum color:
pink and frothy
edema
what conditions are associated with the sputum with:
foul odor
bacterial infection
low blood oxygen level
hypoxemia
most direct way in which the level of oxygen in the blood can be measured
arterial blood gas sampling
A NURSE IS TEACHING HER CLIENT HOW TO OBTAIN A SPUTUM SPECIMEN. IN ORDER TO PROVIDE SAFE AND EFFECTIVE CARE, THE NURSE INSTRUCTS THE PATIENT THAT THE FOLLOWING ACTION WILL FACILITATE OBTAINING THE SPECIMEN?
LIMITING FLUID INTAKE
HAVING THE CLIENT TAKE DEEP BREATHS
ASKING THE CLIENT TO SPIT INTO A COLLECTION
CONTAINER
SUGGESTING TO THE CLIENT THAT THE SPECIMEN BE
OBTAINED AFTER EATING
having the client take deep breaths
Steps to obtain sputum specimen:
TO OBTAIN A SPUTUM SPECIMENT, THE CLIENT SHOULD:
RINSE THE MOUTH TO REDUCE CONTAMINATION
BREATHE DEEPLY
THEN COUGH INTO A SPUTUM SPECIMEN CONTAINER
THE CLIENT SHOULD BE ENCOURAGED TO COUGH AND
NOT SPIT TO OBTAIN SPUTUM
SPUTUM CAN BE THINNED BY FLUIDS OR BY RESPIRATORY
TREATMENT SUCH AS INHALATION OF NEBULIZED
SALINE OR WATER
THE OPTIMAL TIME TO OBTAIN A SPECIMEN IS ON ARISING
IN THE MORNING
IN CARING FOR A CLIENT WITH A TRACHEOSTOMY, THE NURSE WOULD GIVE PRIORITY TO THE NURSING DIAGNOSIS OF:
RISK FOR INEFFECTIVE AIRWAY CLEARANCE
ANXIETY RELATED TO SUCTIONING
SOCIAL ISOLATION RELATED TO ALTERED BODY IMAGE
IMPAIRED TISSUE INTEGRITY
risk for ineffective airway clearance
- WHILE OTHER DIAGNOSES MAY BE APPLICABLE, MAINTAINING A PATENT AIRWAY BY TENDING TO EXCESSIVE SECRETIONS IS A PRIORITY. AIRWAY IS ALWAYS FIRST!!
What are the 3 types of artificial airways?
- nasopharyngeal tube
- oropharyngeal tube
- tracheostomy tube
artificial airway:
- nose
- protect airway
Nasopharyngeal Tube
artificial airway:
- mouth
- protect airway
Oropharyngeal Tube
artificial airway:
- trachea site
- patency with suctioning and oral care importance
Tracheostomy Tube
What are the categories of stress?
distress
eustress
developmental
situational
time
anticipatory
physiological
psychological
can threaten health
ex: financial worries
distress
good stress
ex: passionate kiss
eustress
predictable and associated with life stages
ex:
college graduation
external death of family member
excess heat
internal
disease
anxiety
developmental
random
ex: unpredictable (hurricane/accident)
situational
unable to meet demands (multiple demands)
ex: missed opportunity
time
worried about the future
ex: upcoming exam
anticipatory
affects the body
ex: structure/function (diseases, mobility problems)
physiological
arise from life events
ex:
work pressure
family arguments
stressors throughout the lifespan
psychological
THE HOSPITALIZED CLIENT STATES, “I NEED TO KNOW WHEN IM GOING TO BE DISCHARGED. IM SO UPSET AND WORRIED THAT IM MISSING WORK.” THE NURSE KNOWS
THIS IS AN EXAMPLE OF:“EUSTRESS” AND NO
INTERVENTION IS NECESSARY.
THIS IS AN EXAMPLE OF PSYCHOLOGICAL STRESS AND THE
CLIENT SHOULD BE PLACED ON ANTIDEPRESSANTS.
THIS IS AN EXAMPLE OF DEVELOPMENTAL STRESS AND
THE CLIENT SHOULD TALK TO SOMEONE HIS OWN AGE.
THIS IS AN EXAMPLE OF DISTRESS AND COULD AFFECT THE
CLIENTS HEALTH STATUS
THIS IS AN EXAMPLE OF DISTRESS AND COULD AFFECT THE CLIENTS HEALTH STATUS
- THIS CLIENT’S STATEMENT INDICATES THAT HE IS
EXPERIENCING DISTRESS - EVEN THOUGH IT COULD BE TERMED PSYCHOLOGICAL
STRESS - IT WOULD BE INAPPROPRIATE TO SIMPLY PLACE THE CLIENT
ON ANTIDEPRESSANT THERAPY WITHOUT GATHERING
MORE DATA
T or F:
a client who is taking the drug atenolol (tenormin) may not exhibit the expected rise in blood pressure and pulse during the alarm stage of GAS (general adaptation s yndrome)
True:
- atenolol is classified as a beta-blocking agent
- by preventing epinephrine from binding to beta receptors, this drug would “mask” or lessen the cardiovascular response during the alarm stage
List 4 things to help a patient cope with stress
reflexology
massage
dance
sports
journal writing
aromatherapy
talk therapy
friends
chiropractic adjustments
touch therapy:
- - meditation
- - biofeedback
- - reiki
- - exercise
- - humor
- - art therapy
- - music
- - spirituality
- - acupuncture
What is “GAS”?
General Adaptation Syndrome
what are the stages of “GAS”?
alarm
resistance
exhaustion/recovery
What are psychological defense mechanisms?
avoidance
compensation
conversion
denial
displacement
dissociation
identification
intellectualization
minimization
projection
rationalization
reaction formation
regression
repression
restitution
sublimation
what are somatoform disorders?
physical symptoms with no known cause
- if a person is confronted - leads to extreme anxiety ex-multiple personalities
what are 4 types of somotoform disorders?
- hypochondriasis
- somatization
- somatoform pain disorder
- malingering
preoccupied with disease
they are ill or will become ill
can even imagine symptoms
have a fear they will become worse or become incurable
hypochondriasis
expressed in physical S/S
anxiety and emotional turmoil are expressed
loss of physical function
pain that changes frequently
symptoms that are exaggerated
somatization
chronic pain
emotional pain that manifests physically
source of pain cannot be discovered or exaggerated
somatoform pain disorder
conscious effort to escape mentally
calling in sick to work just because you dont want to go
malingering
THE NURSE SHOULD ASSESS EVERY CLIENT TO DETERMINE IF STRESS REDUCTION INTERVENTIONS SHOULD BE PART OF THE PLAN OF CARE. THE RATIONALE FOR THIS ACTION IS THAT:
THERE ARE MORE PERSONS EXPERIENCING MENTAL
ILLNESS NOW THAN IN THE PAST
LIFE IS SO MUCH MORE STRESSFUL THAN IT HAS EVER
BEEN
THE OCCURRENCE OF STRESS IN CLIENTS IS
UNPREDICTABLE
CLIENTS OFTEN DEVELOP MALADAPTIVE COPING
STRATEGIES
ALL OF THE ABOVE
All of the Above:
- the nurse recognizes that all clients respond differently to healthcare interventions
- therefore, it is important to assess every client’s level of stress to determine if interventions are required
light sleep and slowing brain and body processes are associated with which stage of NREM sleep?
- NREM I
- NREM II
- NREM III
- REM
NREM II
- these are characteristics of a person in stage II of NREM sleep
- 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 CANT SEEM TO THINK CLEARLY.” THE NURSES BEST RESPONSE IS:
“YOU ARE SLEEP DEPRIVED, BUT THAT WILL RESOLVE IN A FEW DAYS”
“YOU ARE EXPERIENCING HYPERSOMNIA, SO IT WILL BE IMPORTANT FOR YOU TO WALK IN THE HALL MORE OFTEN”
“THERE HAS BEEN A DISRUPTION INF YOUR CIRCADIAN RHYTHM. WHAT CAN I DO TO HELP YOU SLEEP BETTER AT NIGHT?”
“I WILL NOTIFY THE DOCTOR AND ASK HIM TO PRESCRIBE A HYPNOTIC MEDICATION TO HELP YOU SLEEP.”
“THERE HAS BEEN A DISRUPTION INF YOUR CIRCADIAN RHYTHM. WHAT CAN I DO TO HELP YOU SLEEP BETTER AT NIGHT?”
- THE DATA SUGGEST THAT THE PATIENT IS USED TO BEING AWAKE AT NIGHT AND SLEEPING DURING THE DAY
- THE HOSPITAL ROUTINE HAS DISRUPTED THIS NORMAL PATTERN
for which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care?
snoring
enuresis
narcolepsy
hypersomnia
narcolepsy
- can occur suddenly during the daytime hours when a person is involved in any type of activity
- this could put the person at risk for harm depending on the activity, in which he or she is engaged
nursing actions include providing oxygen at the ______________, that will correct the hypoxia.
Lowest Liter Flow
what is the flow rate and FiO2 of the nasal canula?
1 - 6 L/min
delivers FiO2 24% - 44% per L
> 4 L/min humidify
what is the flow rate and FiO2 of the simple mask?
6 - 12 L/min
delivers FiO2 35% - 50%
6 L causes rebreathing CO2
what is the flow rate and FiO2 of the non-rebreather (NRB)?
10 - 15 L/min
delivers FiO2 80% - 95%
must keep bag inflated
elevate bed into high fowlers position
can get oxygen toxicity
- cant use longer than 24 hours
what is the flow rate and FiO2 of the venturi mask?
4 - 12 L/min
delivers most precise FiO2 24 - 50% with attachments
best for patient with COPD or Chronic Lung Disease
what is one way to prevent post-operative pneumonia?
us the incentive spirometer to promote maximum lung expansion
what is Cheyne-Stokes respiratory pattern?
- a respiratory pattern that progressively increases and then decreases in depth
- followed by a period of apnea
what are early signs of hypoxia?
tachypnea
tachycardia
hypertension
restlessness
accessory muscles usage
pale skin and mucous membranes
anxiety
confusion
what are late signs of hypoxia?
stupor
cyanosis
bradypnea
bradycardia
hypotension
cardiac dysrhythmias
(extreme) restlessness
what should be your first action when a patient is experiencing respiratory distress?
least invasive first
- place in high fowlers (60 - 90*) which is more effective than semi fowlers, to promote lung expansion and maximize ventilation
what should be your first action if a patients SpO2 is in the 70s?
sit them up in high fowlers
use a nonrebreather
notify the provider of the change
what are symptoms for oxygen toxicity?
change in loc
restlessness
non-productive dry cough
what is the treatment for oxygen toxicity?
lower FiO2 % while maintaining SpO2
what is chest physiotherapy?
a set of techniques that loosen respiratory secretions and move them into the central airways where coughing and suctioning can remove them
what are important points of home oxygen therapy?
OXYGEN THERAPY SYSTEM SHOULD BE KEPT 6 – 10 FEET AWAY FROM A HEAT SOURCE
NO SMOKING
WOOL FABRIC CAN GENERATE STATIC ELECTRICITY
TEACHING CLIENT ABOUT HOW TO USE/CHECK OXYGEN TANK AND REGULAR DELIVERY SERVICE
THROW RUGS ARE A FALL HAZARD
TUBING CAN BE DISTRACTING AND BE A HIGH FALL RISK
CHECK EARS FOR SKIN BREAKDOWN
DO NOT ADJUST OXYGEN WITHOUT CALLING PROVIDER
CHECK THE EQUIPMENT DAILY
OXYGEN SHOULD BE STORED VERTICALLY
what will occur after smoking cessation?
- reverse the negative effects of smoking
- BP and HR decrease
- cough, circulation and SOB will improve
what vaccine is recommended for COPD patients?
pneumococcal vaccine
what age related changes occur with the lungs?
- less lung compliance
- decreased immune response
- less alveolar inflation
- decreased elasticity
- decreased ability to expand the lungs
- more responsibility and roles that are manageable
- common for a student who must work and care for family
role overload
frustration and anxiety when a person feels inadequate for assuming a role
role strain
uncertainty about what is expected
- i.e. starting a new job
role ambiguity
effective
- making healthy choices to reduce negative effects of stress
- exercising to relieve tension, hobbies, seeking support or advice
adaptive coping
ineffective
- doesnt promote adaptation
maladaptive coping
what is unhealthful coping?
overeating
working too much
oversleeping
substance abuse
what occurs in the alarm stage of “GAS”?
fight or flight
- bronchioles dilate to increase oxygen available to muscle, brain, and cardiac cells
- peristalsis decreases
- HR and contractility increase
- increased blood flow to skeletal muscles
- stimulation sympathetic nervous system (SNS)
what occurs in the resistance stage of “GAS”?
body tries to stabilize with coping mechanisms
exhaustion occurs when coping is ineffective resulting in injury, illness, or death
when adaptation is successful
- - client enters recovery
what occurs in the exhaustion stage of “GAS”?
if stress continues and adaptive mechanisms become ineffective, a person enters the final stage, exhaustion
physiological responses that occurs in the exhaustion stage of “GAS”
vasodilation
decreased BP
increased HR and RR
exhaustion usually ends in:
injury
illness
or death
what responses occur with the LAS inflammatory response?
vascular response
cellular response
exudate formation and then healing
begins with a reflex response
what are the risks of chronic stress?
decreased immune response
HTN
stroke
constipation
headaches
memory issues
depleted energy
what changes occur in the body with the stress response?
reduces immune cells ability to differentiate between self and non-self
stress weakens immune system leading to autoimmune illnesses such as:
rheumatoid arthritis
allergies
infection
also causes:
vasoconstriction
high blood glucose
cortisol levels
what are psychosocial stressors?
external stressors that arise from:
- work
- family dynamics
- living situation
- social relationships
- financial strain
what is the term for good healthy stress?
eustress
what are situational stressors?
unpredictable and can include:
- automobile accident
- a natural disaster
- job conflict
- or an illness
what is developmental stress?
- arises from normal life changes
- can be predicted at various stages of life
- going to, losing a parent, having a baby or getting married
what are examples of healthy coping mechanisms?
exercise
journaling
yoga
meditation
spending time with family
eating a balanced healthy diet
doing a hobby
taking vacation days or mental health days
what physiological changes occur during relaxation?
- decrease in BP, HR, RR, and oxygen consumption
- meditation is proven to promote wellness and relaxation
what are 3 NREM stages?
NREM I
NREM II
NREM III
What occurs during NREM I?
light theta
- transition between wake and sleep
- lasts about 5 - 10 minutes
- light sleep
- - - can be awakened easily
- relaxed but aware of surroundings
What occurs during NREM II?
50% sleep
- body temperature drops and HR slows
- brain begins to produce sleep spindles
- lasts approximately 20 minutes
What occurs during NREM III?
deep
- delta 20 - 25% of sleep
- muscles relax
- PARASYMPATHETIC nervous system predominates BP and RR drop
- deepest sleep occurs
- - - difficult to rouse
- - - if awakened may be confused
- some dreams occur but dreams are less vivid
- very important for healing, growth, and tissues renewal
what occurs during the REM stage of sleep?
dreams 20 - 25% of sleep
- brain becomes more active
- body becomes relaxed and immobilized
- dreams occur
- eyes more rapidly
- essential for mental and emotional restoration
- metabolism, temp, HR, and BP increase
- less restful than NREM sleep
- apnea may occur
what biorhythm or biological clock influences wake and sleep time?
circadian rhythm
- 24 hours biological clock
where is biorhythm or biological clock regulated?
regulated in the hypothalamus
how does nicotine impact sleep?
- nicotine causes more difficulty falling asleep and more easily aroused
- temporary sleep disturbances occur during the withdrawal period
what is the cause and symptoms of obstructive sleep apnea?
- due to structures in the mouth and throat that relax during sleep and occlude the upper airway
- could be the adipose tissue
- causes snores, snorts, grunts, or thrashes during sleep
what is insomnia?
most common sleep disorder
- the ability to get an adequate amount of sleep and to feel rested
what are important sleep interventions?
- dont eat before bed
- carbohydrates can cause increase and then a rapid drop in BG
- result in waking up
- avoiding alcohol while taking benzodiazepines
- progressive muscle relaxation and consistent sleep/walk times promote healthy sleep habits
what can the nurse do to promote sleep?
- multiple naps during the day can cause the client to be more awake at night
- coordinate to plan all procedures
- or testing to be done while awake
- keep door closed to reduce outside noise
- carbohydrates such as crackers, cereal, or bread should be avoided
- boost blood glucose levels which can wake the client
what is the impact of chronic sleep loss?
obesity
depression
hypertension
diabetes mellitus
heart attack
stroke
myocardial infarction
infections
possibly cancer
inability to concentrate
poor judgment
moodness
irritability
increased risk for accidents
what is sleep diary?
- specific information about sleep-wakefulness patterns usually over 14 days
- allows identification of trends and associates specific behaviors interfering with sleep
what are nursing actions to create a restful environment and promote comfort?
- linens tight on the bottom and loose on the top to allow movement
- keep linens and gown dry and free of irritants
- close their door
- turn down the lights
- organize their procedures around their sleep time
- control the temperature of the room
- provide good ventilation
- good body alighment
- back rub
- guided imagery
- music therapy
- use earplugs
- warm bed bath or shower
what are important aspects of personal sleep hygiene?
- establish bedtime routine
- regular sleep pattern
- create comfortable environment
- not exercising within 2 hours of sleep
- not drinking alcohol at least 4 hours prior to sleep
- do not use nicotine or caffeine
- dont depend on sleeping aids
what can a nurse do when working night shift to make it easier on the body?
- plan rest days in between consecutive workdays
- engage in conversation with others, not just listen and nod
- do something that requires physical action periodically
- even if it means just getting up and moving around
- take frequent breaks (i.e. every 1 - 2 hours) during the night shift
- dont take caffeine when you dont need it to stay awake, avoid caffeine at the end of your shift before sleep
- practice good sleep hygiene measures during your off hours
