Exam 5 Flashcards
What are the 8 senses involved in sensory reception?
Visual (vision), Auditory (hearing), Olfactory (smell), Gustatory (taste), Tactile (touch), Stereognosis, Kinesthetic & visceral, & Proprioception
What is sterognosis?
Perception of solidity of objects
What are Kinesthetic & Visceral senses?
Basic internal orienting system
What is Proprioception?
The sense that allows an individual to perceive the position and movement of their own body.
What are the 4 conditions to receive data?
Stimulus, Receptor, Nervous pathway to the brain, & Functioning brain to receive & translate impulse into sensation
“Which of the following interventions would be appropriate to stimulate the sense of stereognosis in long-term care residents?
A. Tape pictures of loved ones on the walls.
B. Play soft music in the recreation room.
C. Prepare a fragrant cup of tea.
D. Provide a soft, textured blanket on the bed.”
D. Provide a soft textured blanket on the bed
What are 5 factors affecting sensory stimulation?
Developmental considerations, Culture, Personality & lifestyle, Stress & illness, & Medications
What does the reticular activating system do, and where does is extend to?
Mediates arousal, Monitors & regulates incoming sensory stimuli, maintaining, enhancing, or inhibiting cortical arousal. Extends from hypothalamus to medulla
What are the 2 states of awareness?
Conscious & unconscious
What is Somnolence?
A state of strong desire for sleep or sleeping for unusually long periods.
What are the 4 factors contributing to sensory alteration?
Sensory overload, Sensory deprivation, Sensory deficits, & Sensory poverty
What is sensory overload?
A condition characterized by excessive sensory input leading to discomfort or difficulty processing the environment.
What is sensory deprivation?
The deliberate reduction or removal of stimuli from one or more of the senses.
What is sensory deficits?
Loss or impairment of one or more of the senses.
What is sensory poverty?
A lack of adequate sensory experience that can hinder perception and understanding of the environment.
What causes sensory deprivation?
Environment with decrease or monotonous stimuli, Impaired ability to receive stimuli, & Inability to process stimuli
What are the 3 effects of sensory deprivation?
Perceptual, Cognitive, & Emotional Disturbances
T/F In the drive state of RAS known as sensoristasis, nerve impulses from all the sensory tracts reach the RAS, which then allows certain impulses to reach the cerebral cortex and be perceived.
TRUE
What should nursing care focus with sensory overload?
Reducing distressing stimuli & helping the pt. gain control over the environment
“Which patient would be considered at risk for sensory deprivation?
A. A patient with AIDS
B. A patient in an intensive care unit
C. A patient with a disturbance of the nervous system
D. A patient with intrusive monitoring”
A. A patient with AIDS
What are the 4 parts to assessing the sensory experience?
Stimulation, Reception, Tranmission-perception-reaction, & Defining characterisitics of sensory deprivation & overload
What are the 3 steps to improving sensory functioning?
Teach pt. methods for stimulating senses, Teach pt. with intact and impaired sense self-care behaviors, & Interact therapeutically with pt. with sensory impairments
“Which measure is appropriate when caring for a patient who is hearing impaired?
A. Speak to the patient before making your presence known.
B. Increase noises in the background to stimulate the senses.
C. Position yourself so that light is on your face.
D. Do not use pantomime to express messages to avoid embarrassment.”
C. Position yourself so that light is on your face
What are the 7 steps to communicating with a pt. who is confused?
Use frequent face-to-face contact, Speak calmly, simply, & directly, Orient & reorient pt. to environment, Orient to time, place, & person, Communicate what is expected to be performed, Offer explantaions for care, & Reinforce reality if the pt. is delusional
T/F When caring for an unconscious patient, the nurse should speak loudly and assume that the patient can hear the nurse.
FALSE
What are the 6 classes of nutrients?
Carbohydrates, Protein, Lipids, Vitamins, Minerals, & Water
What is the term for nutrients that supply energy?
Macronutrients (Carbs, Protein, & Lipids)
What is the term for nutrients that regulate body processes?
Micronutrients (Vitamins, Minerals, & Water)
What is the basal metabolic rate?
The rate at which the body expends energy at rest to maintain vital functions.
What are carbohydrates?
A major class of macromolecules composed of carbon, hydrogen, and oxygen, primarily used as a source of energy. Sugars & starches, Most abudant & least expensive nutrient, Classified as simple or complex sugars.
What is protein?
A large molecule composed of one or more long chains of amino acid residues. Required for the formation of all body structures, Complete (high quality) (animal) or incomplete (low quality) (plant),
What are fats?
A type of nutrient that provides energy and helps in the absorption of vitamins, Insoluble in water & blood, Composed of carbon, hydrogen, & oxygen, Digestion occurs largely in the small intestine, & most concentrated source of energy in diet
What are triglycerides?
The most common type of fat found in the body, made up of three fatty acids. 95% of lipids in diet are triglycerides
What are saturated fats?
Fats that are usually solid at room temperature and are found in animal products. (Most animal fats)
What are unsaturated fats?
Fats that are typically liquid at room temperature and are found in plant oils. (Most vegetable fats)
What are trans fats?
Artificially created fats that are harmful to health and found in processed foods.
What are vitamins?
Organic compounds needed by the body in small amounts, Most active form of coenczymes, Needed for metabolsim of carbs, protein, & fat, Classified as water or fat soluble, & Absorbed through intestinal wall
What are minerals?
Inorganic elements found in all body fluids and tissues, Some provide structure others regulate body process, & contained in ash that remains after digestion. Play a big role in fluid balance and clotting
What are some macrominerals?
Calcium, phosphorus (phosphates), sulfur (sulfate), sodium, chloride, potassium, and magnesium
What are some microminerals?
Iron, zinc, manganese, chromium, copper, molybdenum, selenium, fluoride, and iodine
Why is water important?
Accounts for 50-60% of adult’s total weight, 2/3 of body water is contained in cells, Rest in extracellular fluid, Provides fluid medium necessary for all chemical reactions in the body, & Acts as a solvent & aids digestion, absorption, circulation, & excretion
What are some physiologic & physical factors affecting food habits?
Stage of development, state of health, medications
What are some physical, sociocultural, & psycholosocial factors affecting food habits?
Economics, culture, religion, tradition, education, politics, social status, food ideology
What is BMI, and what are the ranges?
Body Mass Index, a measurement calculated from height and weight. Underweight <18.5, Normal 18.5-24.9, Over 25-29.9, & Obesity >30
What are the 3 components of nutritional assessment?
History taking (Dietary, medical, socioeconomic data) , Physical assessments (Anthropometric and clinical data), & Lab data (Protein status, body vitamin, mineral, and trace element status)
What is the worst type of fat on the body?
Belly fat
What are 6 nutrition nursing interventions?
Teach nutritional info., Monitor nutritional status, Stimulate appetite, Assist with eating, Provide oral nutrition, & Provide long-term nutritional support
What is short-term nutritional support?
Temporary nutritional assistance is typically provided via enteral or parenteral routes to patients unable to meet their nutritional requirements orally. Nasointestinal or nasogastric route.
What is long-term nutritional support?
A method of providing essential nutrients to individuals who are unable to meet their nutritional needs through oral intake over an extended period. Enterostomal tube
What are some complications to monitor for with NG, OG, or gastric tubes?
Clogged tubing, Diarrhea, Other GI complications, & Stoma infections
What is TPN?
Total Parenteral Nutrition, a method of feeding that bypasses the gastrointestinal tract. (Problems include: insertion problems, infection, spesis, metabloc alterations, fluid, electrolyte, and acid-base imbalances, phlebitis, hyperlipidemia, & liver & gallbladder disease)
What is phlebitis?
Inflammation of a vein.
T/F Red meat is an incomplete protein
FALSE
“What is the name for the product that occurs when manufacturers partially hydrogenate liquid oils?
A. Lipids
B. Triglycerides
C. Cholesterol
D. Trans fat”
D. Trans fat
“Which one of the following vitamins affects visual acuity in dim light, formation and maintenance of skin and mucous membranes, and the immune function?
A. Vitamin A
B. Vitamin D
C. Vitamin E
D. Vitamin K”
A. Vitamin A
” T/F Food is more vital to life than water because it provides the medium necessary for all chemical reactions and it is not stored in the body.”
FALSE
What is the term for a person of a certain biologic gender who lives full-time as a member of a gender that differs from the sex and gender he/she/they were assigned at birth?
Transsexual
What are the 3 layers of the uterus?
Perimetrium, Myometrium, & Endometrium
What are the 4 phases of the menstrual cycle?
Follicular, Proliferation, Luteal, & Secretory
What is the follicular phase?
1 follicle produces a mature ovum
What is the proliferation phase?
The endometrium becomes thick & velvety
What is the luteal phase?
The corpus luteum (A temporary endocrine structure involved in the menstrual cycle that produces hormones, primarily progesterone.)develops
What is the secretory phase?
The endometrial lining disintegrates
What are some causes of menstrual cycle irregularities?
Pregnancy, breast-feeding, eating disorders, extreme weight loss, extreme exercise, PCOS (polycystic ovary syndrom), premature ovarian failure, PID (pelvic inflammatory disease, & uterine fibroids
Which layer of the uterus comprises tissue that thickens and sloughs off with menses?
Endometrium
What male reproductive gland produces sperm and the hormones necessary for the maintenance of male sex characteristics?
Testes
What are the 4 phases of the sexual response cycle?
Excitement, Plateau, Orgasm, & Resolution
In which phase of the sexual response cycle does involuntary spasmodic contractions of the genital organs occur?
Orgasm
What are 6 factors affecting sexuality?
Developmental considerations, Culture, Religion, Ethics, Lifestyle, & Health state
What are 3 male sexual dysfunctions?
Erectile dysfunction, Premature ejaculation, & Retarded ejaculation
What are 4 female sexual dysfunctions?
Inhibited sexual desire, Dyspareunia, Vaginismus, & Vulvodynia
What are the 3 categories of pt. requiring sexual history?
Seeking care for pregnancy, STI, infertility or contraception, Experiencing sexual dysfunction, & Whose illness will affect sexual functioning
What is level 1 of sexual history?
Part of the comprehensive health history, obtained by a nurse
What is level 2 of sexual history?
Sexual history, obtained by a nurse trained in sexuality
What is level 3 of sexual history?
Sexual problem history, obtained by a sex therapist
What is level 4 of sexual history?
Psychiatric/psychosocial history, obtained by a psychiatric nurse clinician
What are the 4 aspects of obtaining sexual information?
Description of the problem, Onset & cause of the problem, Past attemps at resolution, & Goals of the pt.
What is the BETTER model acronym?
“BRING up the topic of sexuality.
EXPLAIN that you are concerned with all aspects of patients’ lives affected by disease.
TELL patients that sexual dysfunction can happen and that you will address their concerns.
TIMING is important to address sexuality with each visit.
EDUCATE patients about the side effects of their treatments and that side effects may be temporary.
RECORD your assessment and interventions in patients’ medical records .”
What are the 5 pt. outcomes regarding sexuality?
Define individual sexuality, Establish open patterns of communication w/SO, Develop self-awareness & body awareness, Describe responsible sexual health self-care practices, & Practice responsible sexual expression
What are 6 ways to prevent STIs?
Delay having sexual relations as long as possible, Have regular checkups, Learn the common symptoms, Avoid having sex during menstruation, Aviod anal intercourse, & Avoid douching
What are 6 methods of contraception?
Behavioral, Barrier, Hormonal, Intrauterine devices, Emergency contraception, Sterilization
T/F The diaphragm is a barrier method of contraception in which a dome-shaped rubber device is placed in the vagina before sexual activity to prevent semen from coming into contact with the cervix
TRUE
What are 2 forms of sexual harassment?
““Quid pro quo”: something withheld in exchange for something else
Environmental (hostile environment)”
What are 7 aspects of a hostile work environment?
Unwelcome sexually oriented and gender-based behaviors, Sexual bantering, Sexual joking, Offensive pictures and language, Sexual innuendoes, Sexual behavior, & Unwanted attention
What are 5 aspects of responding to pt. advances?
Be self-aware, Confront & provide feedback, Set limits, Enforce stated limits, & Report & Document the incident; submit to supervisor
What are the 5 steps of responding to harassment by colleagues?
Confront the behavior immediately, Document if harassment continues, document the behavior, Consult your supervisor, File if harassment continues, file a grievance w/administration, & Seek legal advice if efforts to stop harassment are unsuccessful
What is oxygenation?
The process of providing oxygen to the body’s tissues. (gas exchange)
What is perfusion?
The flow of blood through the body’s tissues.
What are 3 factors essential to normal functioning of the respiratory system?
Integrity of the airway system, Properly functioning alveolar system, & Properly functioning cardiovascular & hematologic system.
What 4 components make up the upper airway?
Nose, Pharynx, Larynx, & Epiglottis
What is the function of the upper airway?
Warm, filter, humidify, & inspired air
What 4 components make up the lower airway?
Trachea, Right & left mainstem bronchi, Segmental bronchi, & Terminal bronchioles
What is the function of the lower airway?
Conduction of air, mucociliary clearance, production of pulmonary surfactant
What is inspiration and what does it involve?
The active phase of ventilation, Involves movement of muscles & the thorax to bring air into the lungs
What is expiration and what does it involve?
The passive phase of ventilation, Involves the movement of air out of the lungs
What changes occur to the alveoli when the pt. has pneumonia?
Alveoli fills with fluid that prevent gas exchange
What changes occur to the alveoli when the pt. has emphysema?
Alveoli shrink (like raisins)
What is hypoxia?
Inadequate amount of oxygen available to the cells (keep still and in a good position, Reduce workload)
What is dyspnea?
Difficulty breathing (Rest, purse lip breathing, Prevent Anxiety)
What is hypoventilation?
Decreased rate or depth of air movement into the lungs (Wake them up to breath )
What is hyperventilation?
“A condition in which breathing becomes rapid and deep, leading to decreased levels of carbon dioxide in the blood (ventilator set wrong, anxiety attack
- Give paper bag)”
What is dysrhythmia?
An irregular heartbeat or abnormal heart rhythm.
What is a myocardial ischemia?
A condition where blood flow to the heart muscle is reduced, preventing it from receiving enough oxygen.
What is angina?
Chest pain or discomfort due to reduced blood flow to the heart.
What is a myocardial infarction?
Commonly known as a heart attack, it occurs when blood flow to a part of the heart is blocked.
What is heart failure?
A chronic condition where the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs.
What are some common respiratory changes seen in older adults?
Bony landmarks are more prominent, Kyphosis contributes to leaning forward, Barrel chest deformity may result, Tissues & airways become more rigid (diaphragm moves less efficiently), & Increased risk for disease (especially pneumonia)
What are the 5 guidelines for obtaining a resperiatory history?
Determine why pt. needs care, Determine what kind of care, Identify current or potential health deviations, Identify actions performed by pt., & make use of aids to improve intake of air & effects on pt.’s lifestyle
What is vesicular?
Low-pitched, soft sounds during expiration heard over most of the lungs
What is bronchial?
High-pitched and longer, heard primarily over the trachea
What is bronchovesicular?
Medium pitch & sound during expiration, heard over the upper anterior chest and intercostal area
What are crackles in the lungs?
Intermittent sounds occurring when air moves through airways that contain fluid
What are wheezes in the lungs?
Continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors
What are the 5 precautions for oxygen administration?
Avoid open flames, Place “no smoking” signs, Check to see that electrical equipment is in working order, Avoid wearing and using synthetic fabrics, & Avoid using oils in the area
What effect do diuretics have on urination?
Medications that promote the formation and excretion of urine.
What effect do cholinergic medication have on urination?
Drugs that stimulate the parasympathetic nervous system and increase urine production.
What effect do analgesics have on urination?
Medications that relieve pain, which can affect urine production.
What effect do tranquilizers have on urination?
Drugs that induce calmness and can alter urine elimination.
What are 6 types of pt. at risk for UTIs?
Sexually active women, Women who use diaphragms for contraception, Postmenopausal women, Individuals with indwelling urinary catheters, Individuals with diabetes mellitus, & older adults
What is transient urinary incontinence?
Appears suddenly & lasts 6 months or less
What is mixed urinary incontinence?
Urine loss with features of 2 or more types of incontinence
What is overflow urinary incontinence?
Overdistention & overflow of bladder
What is functional urinary incontinence?
Cause by factors outside the urinary tract
What is reflex urinary incontinence?
Emptying of the bladder without sensation of need to void
What is total urinary incontinence?
Continuous, unpredictable loss of urine
What is stress urinary incontinence?
Involuntary loss of urine related to an increase in intra-abdominal pressure
What are the 6 parts of pt. education for urinary diversion?
Explain reason and rationale, Demonstrate effective self-care behaviors, Describe follow-up care and support resources, report where supplies may be obtained, Verbalize related fears & concerns, & Demonstrate a positive body image
What is the primary job of the small intestine?
Secrete enzymes that digest food & absorbs nutrients into blood stream
What is chyme?
A semi-fluid mass of partly digested food that is expelled by the stomach into the small intestine.
What is the primary job of the large intestine?
The part of the digestive system responsible for absorbing water and electrolytes, and for forming and storing feces.
What is peristalsis?
“a sequence of muscle contractions and relaxation controlled by the ANS.
Peristalsis is under control of the nervous system Contractions occur every 3 to 12 minutes – this is why you need to listen for a full minute sometimes.”
Examples of constipation foods
Cheese, lean meat, eggs, & pasta
Examples of foods with laxative effect
Fruits and vegetables, bran, chocolate, alcohol, & coffee
Examples of gas-producing foods
Onions, cabbage, beans, & cauliflower
What color effect does aspirin and anticoagulants have on stool?
Pink to red to black stool
What color effect does iron salts and bismuth subsalicylate (used to treat diarrhea) have on stool?
Black stool (or greenish)
What color effect does antacids have on stool?
White discoloration or speckling in stool
What color effect does antibiotics have on stool?
Green-gray color (maroon)
Why doe we have pt.s bare down during assessment?
To visualize internal hemorrhoids, fissures, bulk of stool (constipation)
What can happen if pt.s bare down?
Compresses the vagal nerve in the brain which regulates heartbeat – this decreases blood flow to the brain – pt passes out
What are the 5 aspects of stool collection?
Medical aspectic technique, hand hygiene before & after, wear disposable gloves, do not contaminate outside of container w/stool, & obtain stool & package, label, & transport according to agency
What are the 5 pt. guidelines for stool collection?
Void first so that urine is not in sample, Defecate into the container not toilet bowl, Do not place tissue, Avoid contact with soaps, detergents, & disinfectants, & Notify nurse when specimen is available
What does an esophagogastroduodenoscopy look at?
Esophages, stomach, & upper duoden
What does a colonoscopy look at?
Rectum, colon, distal small bowel (lower GI bleed)
What does a sigmoidoscopy look at?
Distal colon, sigmoid colon, rectum, & anal canal (lower GI bleed)
What does a wireless capsule endoscopy look at?
Whole GI tract (8hr test, takes pics every 3-5 sec.)
What are the 3 pt. outcomes for normal bowel elimination?
Bowel movement every 1-3 days without discomfort, Relationship bt. elemination and diet, fluid, & exercise is explained, & Pt. should seek medical eval if changes in stool color or consistency persist
What are 4 kinds of individulas at high risk of constipation?
On bedrest taking constipating medicines, Reduced fluids or bulk in their diet, Depressed, Central nervous system disease or local lesions that cause pain while defecating
What are 4 methods of emptying the colon of feces?
Enemas, Rectal suppositories, Oral intestinal lavage, & Digital removal of stool
What are the 6 pt. teachings for colostomies?
Explain reason, Demonstrate self-care behaviors, Describe follow-up & existing support resources, Report where supplies may be obtained, Verbalize related fears & concerns, & Demonstrate a positive body image
“Which food is recommended for an older adult who is constipated?
A. Cheese
B. Fruit
C. Cabbage
D. Eggs”
B. Fruit
“Which of the following direct visualization tests uses a long, flexible, fiberoptic–lighted scope to visualize the rectum, colon, and distal small bowel?
A. Esophagogastroduodenoscopy
B. Colonoscopy
C. Sigmoidoscopy
D. UGI series”
B. Colonoscopy
“Which enema would be used for a patient with intestinal parasites?
A. Oil-retention enema
B. Carminative enema
C. Nutritive enema
D. Anthelmintic enema
“
D. Anthelmintic enema
