QB 12 Flashcards
What kind of foods should the patient with GERD avoid ?
chocolate, peppermint, citrus juices and alcoholic beverages
What to remember about GERD
The client is advised to sleep with the head of bed elevated
eat frequent small meals to prevent gastric distension.
Advise the client not to lie down for 2 to 3 hours after eating, not to wear clothing tight around the waist, or to bend over, especially after eating
Gastroesophageal reflux disease (GERD) may cause pulmonary microaspiration during sleep
Gastroesophageal reflux disease (GERD) is defined as reflux of stomach acid into the lower esophagus that can cause pain and result in inflammation that eventually may lead to mucosal damage. The client may report pain or a burning sensation in the lower esophagus or upper abdomen, nocturnal coughing, hoarseness, sore throat, and shortness of breath. Listen to lung sounds to assess for possible aspiration of stomach acid. Instruct client to avoid foods and activities that cause acid reflux, such as alcohol and late night eating. Short-term, rapid-acting medications (e.g., antacids or histamine 2 receptor blockers) or long-term acid control medications (e.g., proton pump inhibitors) may be prescribed.
The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client helps the nurse determine that teaching was effective?
- “If my stomach feels bloated, I will drink peppermint tea.”
- “I will switch from orange juice to tomato juice at breakfast.”
- “I will eat three meals per day and not snack between meals.”
- “I will raise the head of my bed 12 inches prior to sleeping each night.”
1) INCORRECT - Peppermint exacerbates reflux, as does caffeine, and should be avoided in treating the disease.
2) INCORRECT - Both juices are acidic and exacerbate reflux. Apple juice is an appropriate alternative.
3) INCORRECT - Big meals exacerbate reflux by increasing volume and pressure in the stomach, as well as delaying gastric emptying. It is best to eat six small meals per day.
4) CORRECT— The recumbent position significantly impairs esophageal clearance. The client’s head should be elevated 6 to 12 inches to prevent nighttime reflux.
What to remember about therapeutic massage
therapeutic massage helps return blood flow to the heart and enhances muscle tone and joint function.
Therapeutic massage has many benefits, such as the stimulation of circulation; promotion of sleep; and reduction of muscle tension, stress, and anxiety. While massage can promote circulation for immobile clients, the nurse should avoid massaging or rubbing reddened or discolored areas
Primary, Secondary, and Tertiary Prevention
Primary prevention refers to measures such as diet, proper exercise, and immunizations to prevent the occurrence of a specific disease.
Secondary prevention refers to early detection of disease that can lead to interventions to prevent disease progression (e.g., biometric screening, physical examination, eye examinations, and mammography).
Tertiary prevention refers to activities that limit disease progression, such as rehabilitation.
Primary prevention reduces the likelihood of developing a health alteration. For cancer prevention, general health promotion strategies include
eliminating the use of tobacco and alcohol, adding antioxidant-rich foods, (A substance that prevents or delays cellular damage. It is often found in fruits and vegetables) reducing nitrate-rich foods (A preservative used in processed meat. It is known to cause cancer and heart disease) , increasing activity levels throughout the day, maintaining a healthy weight, and managing stress.
What to remember about vitreous hemorrhage
A vitreous hemorrhage can result in loss of vision.
If the vitreous hemorrhage does not spontaneously resolve, surgery may be required
Vitreous hemorrhage is the extravasation, or leakage, of blood into the areas in and around the vitreous humor of the eye. The vitreous humor is the clear gel that fills the space between the lens and the retina of the eye.
The symptoms of vitreous hemorrhage are varied but usually include painless unilateral floaters and/or visual loss. Cobwebs, haze, shadows, and red hues are words that may be used to describe an early or mild hemorrhage. The nurse may ask the client about possible risk factors such as a history of trauma, ocular surgery, diabetes mellitus, sickle cell anemia, leukemia, carotid artery disease, and high myopia. The nurse may explain to the client that a complete examination of the eyes is warranted. The nurse can explain to the client which procedure to anticipate, such as dilated examination of the contralateral eye to help provide clues to the etiology of the vitreous hemorrhage, such as proliferative diabetic retinopathy.
Nitrates in urine indicate an E. coli infection.
TRUE OR FALSE
TRUE
the Haemophilus influenzae type B (Hib) vaccine, prevents the development of bacterial ____________, which can lead to death
meningitis
Meningitis is the inflammation of the meninges, which are protective coverings of the brain and spinal cord, that may result in infection caused by bacterial, viral, or fungal pathogens. Age is a factor that influences the risk of developing meningitis. Infants, older adults, and debilitated persons are most at risk. People who live in environmentally close settings are also more susceptible. Individuals who have not been immunized for mumps, Haemophilus influenza, and Streptococcus pneumoniae are also at a greater risk. Because of this, prevention is essential. Primary prevention includes activities that promote health and prevent illness (e.g., immunizations).
Is it normal for the postpartum client to urinate frequently and in large amounts ?
YES
Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected.
Liquid medication may contain sorbitol, which can cause diarrhea.
TRUE OR FALSE
TRUE
Behaviors and skills are expected to develop within a certain time frame during infancy and childhood. Examples include physical abilities, social behaviors, emotional responses, cognitive abilities, and communication skills. Each developmental task is usually given a wide range of ____________ months during which the milestones should be reached. The range accounts for the client’s individualized characteristics. When milestones are not reached on time, the nurse is concerned that the client may have a_________________-
3-6;
developmental delay caused by a pathophysiological process.
The nurse provides care for a client with an abdominal abscess draining into a bulb suction device. Which is the most important data for the nurse to assess when monitoring the drainage?
- Amount.
- Color.
- Consistency.
- Site leakage.
1) INCORRECT - Whether the amount trends down or trends up gives useful information about the client’s status. However, it is not the most important information.
2) CORRECT - Assessing whether the drainage is purulent, sanguinous, serosanguineous, etc. is the most important characteristic to document. Dark green or yellow drainage may indicate the client has not improved. Pale yellow serous drainage may indicate clearing of the infection.
3) INCORRECT - Consistency is important. If the client is draining thin drainage versus thick drainage, the health care provider may determine the infection is beginning to resolve. However, the consistency alone is not the most important information.
4) INCORRECT - It is important to note if there is drainage around the tube and at the site. This is a common occurrence, and is not the most important information.
The color of the drainage helps determine the degree of healing, the presence of an infection, or if an infection is improving. The amount of drainage will depend upon the location of the drain, the organ or site being drained, and the client’s activity level. Consistency helps determine the status of an infection, but is not the most important characteristic.
Wound healing involves prevention of infection, promoting blood flow, increasing nutritional stores to encourage tissue growth, and use of dressings to cover, manage drainage, and keep the wound bed moist. When managing drains, the nurse needs to assess the ____________________–of the drainage.
color, amount, and characteristic
The client with a brain tumor is at risk for increased __________________. Utilize the ________________to assess level of consciousness. Notify the health care provider (HCP) immediately if there is a change in _____________________Implement neurological checks and monitor vital signs. The nurse can anticipate changes in the client’s functioning dependent upon the area of the brain affected by the tumor. For clients with a frontal lobe tumor, the nurse can expect to see a deterioration or significant change in ____________________-
intracranial pressure; Glasgow Coma Scale; level of consciousness; motivation, planning, sustained mental effort, problem solving, and personality.
