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Fundamentals Of Nursing Theory > Study Guide Test 4 > Flashcards

Study Guide Test 4 Flashcards

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1
Q

An optimal nutritional status provides what?

A

sufficient energy for daily activities

maintenance and replacement of body cells and tissues

restoration of health following illness or injury

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2
Q

Who would be more at risk for having inadequate nutritional intake?

A
  • Older adults who are socially isolated or living on fixed incomes
  • Homeless people
  • Children with low socioeconomic status
  • Pregnant teenagers
  • People with substance abuse problems, such as alcoholism
  • Clients with eating disorders, such as anorexia nervosa and bulimia nervosa
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3
Q

What is a protein and what are they made from?

A

Protein, a component of every living cell, is a nutrient composed of amino acids, which are chemical compounds composed of nitrogen, carbon, hydrogen, and oxygen. Amino acids are responsible for building and repairing cells.

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4
Q

are protein components that must be obtained from food because the body cannot synthesize them. (There are 9)

A

Essential Amino Acid

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5
Q

are protein components manufactured within the body; “Nonessential” refers to the fact that these amino acids are not dependent on dietary intake. (not that they are unnecessary for health)

A

Nonessential Amino Acid

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6
Q

What do proteins do for our bodies?

A

*build tissue
*maintain tissue
*repair tissue

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7
Q

high-density lipoprotein is referred to as “good cholesterol,” cholesterol is delivered to the liver for removal

A

HDL’s

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8
Q

Low-density lipoprotein are called “bad cholesterol” because the cholesterol is deposited within the walls of arteries.

A

LDL’s

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9
Q

What is the purpose of minerals and vitamins?

A

Minerals help regulate many of the body’s chemical processes such as blood clotting and the conduction of nerve impulses. Vitamins are chemical substances necessary in minute amounts for normal growth, the maintenance of health and the functioning of the body.

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10
Q

thiamine

A

B1

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11
Q

riboflavin

A

B2

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12
Q

niacin

A

B3

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13
Q

pyridoxine

A

B6

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14
Q

folic acid

A

B9

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15
Q

cyanocobalamin

A

B12

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16
Q

ascorbic acid

A

C

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17
Q

retinol

A

Fat A

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18
Q

calciferol

A

Fat D

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19
Q

alpha-tocopherol

A

Fat E

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20
Q

menadione

A

Fat V

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21
Q

Which of these require daily replacement and why?
Fat Or Vitamins?

A

Water-soluble vitamins are eliminated with body fluids and so require replacement

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22
Q

This diet can be inadequate in: Protein

A

Vegetarian/Vegan

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23
Q

What are some items that should be considered when taking a diet history?

A

§ The level of appetite
§ Unintentional weight loss or gain of 10% in the past 6 months
§ The number of meals the client eats per day
§ Foods (in approximate household measurements) that the client has eaten in the previous 24 hours
§ Time when the client generally eats meals
§ Frequency with which the client eats meals alone
§ Food likes, dislikes, allergies, intolerances, and cultural beliefs about food
§ The amount of alcohol the client consumes daily or weekly
§ Vitamin or mineral supplements the client takes routinely
§ Any problems with eating, digestion, or elimination
§ Special diets that have been medically prescribed or self-imposed
§ The use of over-the-counter (OTC) drugs, such as antacids or laxatives
§ Food supplements or restrictions and the reasons for them
§ The desire to improve nutritional intake or to gain or lose weight

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24
Q

BMI

A

Body Mass Index height and weight

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25
Q

At what point is a person considered obese?

A

30 kg/m2

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26
Q

What would increased abdominal fat put a person at risk for?

A

*Diabetes
*Cardiovascular disease

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27
Q

In an elderly client, would exercise increase or decrease their appetite?

A

• It would increase an olders clients intake of calories and nutrients. It improves appettite and over all health.

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28
Q

Basic Anorexia:

A

A loss of appetite is associated with multiple factors illness, altered taste and smell , oral problems, and tension and depression.

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29
Q

What is the goal for anorexia client?

A

• Cater to the clients food preferences. The client will more likely consume food he or she selects.
• Serve nutrient dense foods ( foods loaded with calories) they may compesate for a low intake of food.
• Offer small servings of food frequently. EAting small amounts frequently may result in a cumlative intake within acceptable nutritional levels.

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30
Q

How would the nurse determine if the client’s goal has been met?

A

• The client demonstartes technique for clearing the mouth of food
• The clinent consumes suffiecent calories to maintain a weight
• The clinet swallows food completely

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31
Q

What is nausea?

A

Usually precedes vomiting and is produced when gastrointestinal sensations, sensory data, and drug effects stimulate a portion of the medulla that contains the vomiting center.

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32
Q

What signs/symptoms are usually associated with nausea?

A

• Dizziness
• Perspiration
• Skin pallor
• A rapid pulse rate
• Headache

33
Q

What can you do to help with a client who is feeling nauseated?

A

• Check to see if something as simple as an annoying odor or sight is contributing to nausea. Offensive sensory data can stimulate the vomiting center in the brain.
• Assist the client with taking deep breaths. Distraction can overcome nausea by directing conscious attention away from the unpleasant sensation.
• Limit the client’s abrupt movements and activities. Movement may shift gastrointestinal structures and their contents, intensifying stimulation of the vomiting center.
• Limit the client’s intake of food and fluid temporarily until nausea subsides. Distention of the stomach is a common trigger of the vomiting center.
• Avoid making negative comments about food. Verbal comments create visual images that may cause psychogenic stimulation of the vomiting center.

34
Q

(a loss of stomach contents through the mouth) commonly accompanies nausea.

A

Vomiting

35
Q

(the act of vomiting without producing vomitus) may occur if the stomach is empty.

A

Retching

36
Q

(bringing stomach contents to the throat and mouth without the effort of vomiting) occurs commonly among infants after eating.

A

Regurgitation

37
Q

(vomiting that occurs with great force) is associated with certain disease conditions such as increased pressure in the brain or gastrointestinal bleeding.

A

Projectile Vomiting

38
Q

(belching) is a discharge of gas from the stomach through the mouth.

A

Eructation

39
Q

What are some preventative measures for reducing gas in a client’s stomach?

A

• Suggest that the client chew food with the mouth closed. Laughing and talking while eating increase the amount of swallowed air.
• Advise against using a straw. Each swallow of liquid also contains the air in the straw.
• Advise against chewing gum and smoking cigarettes. Chewing gum increases salivation and results in swallowing both secretions and air. The client actually may swallow a portion of inhaled cigarette smoke.
• Limit or restrict foods that contain large volumes of air such as soufflés, yeast breads, and carbonated beverages. Swallowing air trapped within food and drinking beverages that contain dissolved gas distend the stomach.
• Recommend that when under stress, the client avoid eating. Emotions delay stomach emptying, which prevents the movement of gas to the intestine.
• Propose walking if uncomfortable. Activity helps gas to rise to its highest point in the stomach, making belching easier.
• Consult with the physician about the use of medications that relieve gas accumulation. Instruct clients who purchase OTC drugs to follow label directions for their use. Simethicone is an ingredient in several nonprescription antacids. Drugs containing simethicone facilitate the elimination of gas by reducing the surface tension of gas bubbles trapped in the gastrointestinal tract.

40
Q

allows unrestricted food selections

A

Regular Diet

41
Q

contains foods soft in texture; is usually low in residue and readily digestible; contains few or no spices or condiments; provides fewer fruits, vegetables, or meats than a light diet

A

Soft Diet

42
Q

contains fruit, pudding, milkshakes, gelatin, junket, custards, and cooked cereals

A

Full Liquid diet

43
Q

consist of items that may be colored, but are generally transparent and do not contain any pulp or bits of food; examples include water, broth, fruit juices, flavored gelatin, popsicles, clear soft drinks, tea, and coffee

A

Clear Liquid diet

44
Q

Feeding clients with Dysphagia:

A

§ Always have equipment for oral and pharyngeal suctioning at the bedside
§ Remain with the client throughout eating when there is a potential for aspiration
§ If the client has a tracheostomy tube or endotracheal tube, make sure the cuff is inflated
§ Place the client in a sitting position
§ Ensure that the client is rested and that you have his or her attention
§ Give short, simple, instructions to prompt the client to eat and swallow
§ Limit distracting stimuli; turn off the television and reduce or eliminate activities taking place in the area
§ Request a full liquid or mechanically soft diet for the client who has missing teeth or has recently had oral surgery
§ Provide small frequent meals if efforts to eat and swallow tire the client
§ Modify eating or feeding equipment to facilitate the client’s safety and independence
§ Determine that the client has swallowed one portion of food before offering another
§ Encourage repeated swallowing attempts if there is wet, gurgly, vocalization, a sign that food is in the esophagus and not the stomach

45
Q

Feeding the Visually Impaired Client:

A

§ Place a thick towel across the client’s chest and over the lap
§ If the client can eat independently, consider using dishes with rims or bowls to prevent spilling
§ Arrange as much as possible to have finger foods prepared for the client
§ Describe the food and indicate its location on the tray
§ Guide the client’s hand to reinforce the location of food and utensils
§ Prepare the food by opening cartons, cutting bite-size pieces, adding salt and pepper, buttering bread, and pouring coffee
§ Use the analogy of a clock when describing where the client may find food on the plate. For example, “The potatoes are at 3 o’clock.”
§ If the client needs to be fed, tell him or her what kind of food you are offering with each mouthful.
§ Devise a system by which the client can indicate when he or she is ready for more food or drink, such as asking or raising a finger.
§ Do not rush the client; eating should be done at a leisurely pace.

46
Q

Visually Impaired

A

§ Place a thick towel across the client’s chest and over the lap.
§ If the client can eat independently, consider using dishes with rims or bowls to prevent spilling.
§ Arrange as much as possible to have finger foods (foods that may be eaten with the hands) prepared for the client.
§ Describe the food and indicate its location on the tray.
§ Guide the client’s hand to reinforce the location of food and utensils.
§ Prepare the food by opening cartons, cutting bite-size pieces, adding salt and pepper, buttering bread, and pouring coffee.
§ Use the analogy of a clock when describing where the client may find food on the plate. For example, “The potatoes are at 3 o’clock.”
§ If the client needs to be fed, tell him or her what kind of food you are offering with each mouthful.
§ Devise a system by which the client can indicate when he or she is ready for more food or drink, such as asking or raising a finger.
§ Do not rush the client; eating should be done at a leisurely pace.

47
Q

refers to the deterioration of previous intellectual capacity.

A

Dementia

48
Q

Useful nursing actions: Dementia

A

Have the same staff person help the client
Be consistent with the time and place for eating
Reduce or eliminate environmental distractions to promote concentration on the task at hand
Place the food close to the client
Remove wrappers, containers, and food covers to reduce confusion
Pour milk from the carton into a glass so that it easily recognizable

49
Q

Visual impairment: when caring for clients who are temporarily or permanently sightless:

A

Place a thick towel across the client and over the lap
If the client cant eat independently, consider using dishes with rims or bowls to prevent spilling
Arrange as much as possible to have finger foods
Describe the food and indicate its location on the tray
Guide the client’s hand to reinforce the location of food and utensils
Prepare the food by opening cartons, cutting bite size pieces, adding salt and pepper, buttering bread, and pouring coffee

50
Q

What are some gerontologic considerations that should be considered?

A

Dry mouth is common in older adults and is often caused by medications or the effect of the disease. It interferes with chewing, swallowing, and enjoying meals.
Oral infections, poorly fitting dentures, or vitamin deficiencies can cause a painful or burning tongue, ulcers on the gums, or other difficulties that interfere with eating.

51
Q

Infants/Toddlers

A

Infants: (rely on the safety consciousness of their adult caregivers) falling off changing tables or being unrestrained in automobiles. Toddlers: (fail to understand the consequences of danger) accidental poisoning, falls down the stairs or from high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning

52
Q

School Aged/Adolescents

A

sports-related injuries—before their musculoskeletal systems can withstand the stress; also tend to be impulsive and take risks as a result of poor judgment and peer pressure

53
Q

Adults

A

(ignores safety issues) driving while texting or talking on a cell phone, failing to use seat belts, fatigue, sensory changes, and effects of disease.

54
Q

Young adults

A

(Alcohol and drug abuse; Emancipation from parental supervision; Naiveté about workplace hazards) Motor vehicle collisions, Boating accidents; Head and spinal cord injuries, Eye injuries, chemical burns, traumatic amputations, and soft tissue and back injuries

55
Q

Middle-aged adults

A

(Failure to use safety devices; Overexertion and fatigue; Disregard for use of seat belts and car safety harnesses; Lack of expertise in performing home maintenance or repairs) Physical trauma (see previous) Burns and asphyxiation related to nonfunctioning smoke, heat, and carbon monoxide detectors

56
Q

Older adults

A

(Visual impairment; Urinary urgency; Postural hypotension; Reduced coordination; Impaired mobility; Inadequate home maintenance; Mental confusion; Impaired temperature regulation) Falls, Poisoning/medication errors, Hypothermia and hyperthermia, Scalds and burns

57
Q

Latex allergies are on the rise.

A

Latex allergies are on the rise. What kind of questions and what should you do for a client who is suspected of or they have a latex allergy?
You would ask questions like, are they allergic? Have they had a reaction in the past? Are they allergic to avocados? Bananas? Almonds? Peaches? Kiwi? Tomatoes?
Client can wear a medic alert bracelet, advise employer health officer, communicate with personnel, stock latex free or latex safe products, assign client to a private room

58
Q

What does the acronym RACE stand for?

A

R- Rescue
A-Alarm
C-Confine the fire
E-Extinguish

59
Q

What is your role in a fire?

A

Rescue clients in immediate vicinity of the fire. Nurses lead those who can walk to a safe area and close the room and fire doors after exiting. Using a variety of techniques nursing personnel evacuate those who cannot walk.

60
Q

Carbon Monoxide is more dangerous than smoke because it is odorless. What should be done for a person who is suspected of having CO inhalation?

A

Get the victim out of the present environment. If moving the person out doors is impossible, rescuers should open windows and doors to reduce the level of toxic gas and promote adequate ventilation.

61
Q

List S/S of CO poisoning:

A

Dizziness, visual disturbances, headache, cherry red skin color, confusion, muscle weakness, muscle cramps, seizures, nausea and vomiting

62
Q

Can drowning only occur in a swimming pool? What should a nurse include in education to parents about drowning?

A

No, swimming pools should be fenced and locked. Children should never be left unattended in a bathtub or pool

63
Q

How can drowning be prevented?

A

*learn to swim
*never swim alone
*wear approved flotation device
*do not drink alcohol when participating in water related sports
*notify law enforcement officer if boater appears unsafe

64
Q

What reduces the potential for electrical shocks?

A

A conductor is a substance that facilitates the flow of electrical current; an insulator is a substance that contains electrical currents, so they do not scatter. Electric cords are covered with rubber and some other insulating substances.

65
Q

What can prevent electrical shocks?

A

Use of ground equipment in the home and health care agency reduces the potential for electrical shock. The ground diverts leaking electrical energy to the earth. Grounded equipment can be identified by the presence of a three-pronged plug.

66
Q

What is considered to be a poisoning/ Ingestion?

A

Poisoning is injury caused by the ingestion, inhalation, or absorption of a toxic substance. These are more common in homes than in health care institutions, though medication errors could be considered a form of poisoning.

67
Q

What should you do if you suspect a poisoning has occurred?

A

Initial treatment for a victim of suspected poisons involves maintaining breathing and cardiac function. Definitive treatment depends on the substance, the client’s condition, and if the substance is still in the stomach. For ingestions of commercial products containing multiple ingredients, the poison control center is consulted.

68
Q

Assessment What can be done?

A

Assessment: determining which clients are at higher risk can prevent some falls. Identifying high risk clients and preventing falls is also an NPSG.

69
Q

Prevention of falls… What can be done?

A

Prevention:
• Keep the environment well lit
• Install and use handrails on stairs inside and outside the home
• Place a strip of light colored adhesive tape on the edge of each stair for visability
• Remove scatter rugs
• Keep extensions cords next to the wall
• Do not wax floors
• Wear well-fitting shoes that enclose the heel and toe of the foot and have nonskid soles
• Keep pathways clutter free

70
Q

are methods that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head.

A

Physical restraints

71
Q

are medications that are not a standard treatment or dosage for the clients condition but rather are used to manage a clients behavior or freedom of movement.

A

Chemical restraints

72
Q

What are some consequences of restrained clients?

A

It is unethical and a violation of TJC’s standards to use physical or chemical restraints for disciplinary reasons or to compensate for limited personnel. Restraints must be the last intervention after trying all other measures to solve the problem.

73
Q

What is a restraint protocol?

A

is a plan or set of steps to follow when implementing an intervention, during a TJC inspection, the accrediting team examines an agency’s protocol for restraint use that the medical staff has approved. The protocol must identify the criteria that justify the application and discontinuation of restraints.

74
Q

When must an order be received for restraints and how long is it legally binding?

A

physician must write a restraint order, or a nurse must obtain one from a physician by telephone within 1 hour after the restraint is initiated. If a physician is unavailable, a registered nurse who has knowledge, training, and experience in the techniques that necessitate the use of restraints may initiate restraint use based on appropriate assessment of the client.

75
Q

After restraints have been applied, what are the nursing responsibilities?

A

The client’s chart must contain documented evidence of frequent and regular nursing assessments of the restrained client’s vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing restraint.

76
Q

What are some alternatives to using restraints?

A

Some examples include seat inserts or gripping materials that prevent sliding, support pillows, seat belts or harnesses with front-releasing Velcro or buckle closures, and commercial or homemade tilt wedges.

77
Q

What should you as a nurse know about restraints? (Monitoring & Documentation)

A

The documented care must reflect the agency’s established protocol. The nurse also promptly communicates with the client’s family regarding the need for restraints and notes the time in the documentation. When the assessment findings indicate that the client has improved, the nurse must legally and ethically remove the restraint.

78
Q

What should be assessed and documented frequently during the use of restraints?

A

client’s vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing restrain

79
Q

Restraints must be the _________________resort or intervention used.

A

last

Fundamentals Of Nursing Theory (6 decks)

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