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.
The frontal lobe of the brain controls __________________________
voluntary activity, executive function, personality, concentration, motivation, ability to plan, and problem solving.
Syndrome of inappropriate antidiuretic hormone (SIADH) is an endocrine disorder in which there is an excess production of antidiuretic hormone resulting in hypervolemia, dilutional hyponatremia, and highly concentrated urine. Risk factors for SIADH include _________________________
traumatic brain injury, stroke, meningitis, neoplasms in lungs and colon, pulmonary disorders (emphysema), and adverse effects of anesthetics, barbiturates, or selective serotonin reuptake inhibitors.
Who is at risk for contracting hepatitis?
Individuals traveling to foreign countries and those who may consume contaminated foods or fluids are at risk for contracting hepatitis A.
A lack of a sanitary water supply or the ingestion of vegetables or fruits exposed to infectious waste pose a risk for hepatitis A
Persons traveling to countries with high to medium rates of hepatitis should be vaccinated. Countries in Africa, South America, and Asia have high to medium rates of hepatitis A due to inadequate water sanitation.
During a surgical procedure, an anesthesia care provider delivers anesthesia, medications that produce local, regional or general effects, such as sedation, loss of reflexes, freedom from pain, loss of sensation, and relaxation.
TRUE OR FALSE
TRUE
The client who has an allergy to a medication in the same drug class should be questioned about that allergy prior to administration of a related medication.
TRUE OR FALSE
TRUE
In addition, the health care provider (HCP) should be contacted to clarify the medication prescription. Many related medications have the potential to evoke the same allergic reaction. Depending on the type of allergy the client experienced, the HCP may proceed with the newly prescribed medication or may have made an error and wish to change to a different medication.
Tips for deescalating a situation when clients, visitors, or staff are angry or upset
. Strategies for defusing conflict include stating objective observations, such as “you seem frustrated,” rather than immediately questioning an individual about details of the situation. At the height of conflict, asking “why” may be perceived as confrontational and can exacerbate a volatile situation. Acknowledging feelings and providing appropriate validation are effective strategies to help the individual feel heard and understood, which in turn may decrease the individual’s sense of frustration.
Non-pharmacologic interventions may reduce analgesic doses required to alleviate pain, thus minimizing side effects of drug therapy
TRUE OR FALSE
TRUE
Non-pharmacologic interventions may reduce analgesic doses required to alleviate pain, thus minimizing side effects of drug therapy. Non-pharmacologic interventions may also increase the client’s sense of personal control and coping skills. Examples of non-pharmacologic interventions to manage pain include massage, exercise (physical deconditioning can actually lead to increased pain), transcutaneous electrical nerve stimulation (TENS), acupuncture, heat therapy, cold therapy, distraction, hypnosis, and relaxation strategies (e.g., relaxation breathing, music, imagery, meditation, muscle relaxation, and art).
For treatment of chronic pain that is not associated with cancer or the dying process, research indicates non-opioid medications and non-pharmacologic therapies may safely and effectively relieve pain. However, opioids are considered to be first-line therapies for treatment of moderate to severe pain related to cancer. Opioids are also indicated for administration during palliative care and end-of-life care
TRUE OR FALSE
.
TRUE
Side effects of opioids include respiratory depression, sedation, and constipation. Adding non-pharmacologic pain control measures may enhance the client’s relaxation and sense of well-being; however, the client likely will continue to need opioid medication to provide sufficient pain relief.
Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables.
TRUE OR FALSE
TRUE
Because diabetes is a primary risk factor for heart disease, client education emphasizes selecting low-carbohydrate meal options and adding taste without increasing fat content
_____________________________________are clinical manifestations of fluid volume deficit or dehydration. However, as aging occurs, the epidermis thins and the decrease of subcutaneous tissue causes a loss of elasticity and moisture. Because of this, _________________-is not the most reliable method to determine an older adult client’s hydration status.
Thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy’ skin turgor
Alternatively, one can pinch a fold of skin over the chest wall, which is less likely to be affected by aging and sun exposure.
Wound Care Dressing Change Guidelines
apply clean gloves, removes the soiled dressing, don sterile gloves, and perform a sterile dressing change.
A soiled dressing is removed wearing clean gloves. After the clean gloves are removed and the hands washed, sterile gloves are applied to change the sterile dressing. Sterile gloves are not required to remove the dressing.
To complete a dressing change, the nurse needs to apply clean gloves to remove old dressings. Perform wound irrigation, cultures, or cleansing as indicated by health care provider prescriptions. Since this is an open wound, apply new dressings using sterile technique. Document the wound appearance, including size, location, amount of exudate, condition of skin surrounding the wound, and client tolerance of dressing change procedure.
Maslow’s hiearchy of needs
Maslow’s hierarchy of needs is a theory of human needs that prioritizes and motivates human behavior. It begins with physiologic needs (food, air, water), then moves to safety and security, then to love and belonging, self-esteem, and self-actualization. The theory states that as each level is met, the individual will strive to meet the next level.
If a blood pressure cuff is too small, the measurement will be falsely elevated. If the blood pressure cuff is too large, the measurement will be falsely low.
TRUE OR FALSE
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff cannot record brachial artery measurements unless it is excessively inflated.
2small= false high
2large= false low
When assessing the degree of response to pain, the nurse should begin with this least pain-causing approach and progress to the action, which is known to cause the most amount of pain.
TRUE OR FALSE
TRUE
The nurse understands that coma is a change in level of consciousness in which the client does not interact with the environment. In this state of consciousness, the client is unable to react to painful stimuli.
TRUE OR FALSE
TRUE
Coma is a prolonged state of unconsciousness during which a client is unresponsive to the environment and cannot be awakened by any stimulation, including pain. The types of coma include toxic-metabolic encephalopathy, anoxic brain injury, persistent vegetative state, locked-in syndrome, brain death, and medically induced. Diagnostic testing includes history, general physical examination, and neurologic examination, including eye examination. The Glasgow Coma Scale (GCS) should be used. The GCS is a standardized assessment tool that uses scaled scores to assess level of consciousness.
What to remember about Glasgow Coma Scale
The higher score indicates a higher level of neurological functioning. The maximum score is 15 and the minimum score is 3.
The Glasgow Coma Scale (GCS) is a standardized assessment tool that uses scaled scores to assess level of consciousness. The components of level of consciousness that are assessed using the GCS include verbal response, motor response, and eye opening.
Scores are rated in each category for the client’s best response.
When deciding who to see first, Client care issues take priority over staff issues.
TRUE OR FALSE
TRUE
Nursing responsibilities includes knowing about side effects and adverse effects of medication. The nurse only contacts the pharmacy if unable to review the medication in a reliable drug formulary.
TRUE OR FALSE
TRU
Health literacy skills have been shown to be a stronger predictor of health status than age and educational level.
TRUE OR FALSE
TRUE
Pre-operative teaching is a great opportunity to educate the client on post-operative health promotion and maintenance. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations.
The nurse should assist a client to understand and mentally prepare for surgery and the post-operative recovery period. Assess the client’s perceptions of the surgical process. Assess client anxiety pre-operatively. Assess client and family current knowledge, health literacy, any barriers to learning, and learning needs. Ideally, pre-operative teaching occurs before admission. Utilize informational pamphlets, videos, and individualized and structured instruction with return demonstration. Supplement with website programs that explain procedures and specific information about the specific surgery, if applicable.
Wound healing is a process to restore tissue integrity by primary or secondary intention. 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.
TRUE OR FALSE
TRUE
Most surgical incisions heal by primary intention, i.e. the edges of the surgical incision are closed together with stitches or clips until the cut edges merge. Healing by secondary intention refers to healing of an open wound, from the base upwards, by laying down new tissue
