Week 3- Sensory (Audio/Vision) + G.I. Review Q's Flashcards
Auditory Disorders - __________ Ear
– Trauma
– Inflammation and infection
– Cerumen and foreign bodies in ear canal
– Skin cancer
External
Auditory Disorders - ________ Ear Problems
-Meniere’s Disease
-Benign paroxysmal positional vertigo
-Conductive or Sensorineural hearing loss
-Acoustic Neuroma
Inner
Auditory Disorders - ____________ ear
- Acute/Chronic otitis media
- Otosclerosis (genetic)
Middle Ear / Mastoid
Otitis Media (often in children) - inflammation of ________________
– Antibiotics
– Tympanoplasty (myringotomy tubes)
middle ear
Otosclerosis - abnormal bone growth within the middle ear that causes progressive hearing loss.
Tx: ___________________
Stapedectomy [surgery to remove stapes]
Tinnitus
– Caused by many __________
– Consider other medications that don’t cause tinnitus
– _________________ to drown out the ringing may be considered
– Caused by many medications
– Consider other medications that don’t cause tinnitus
– Hearing aid to drown out the ringing may be considered
Meniere’s disease - inner ear problem that can cause __________________________
– Minimize vertigo
– Darkened quiet room
– Avoid sudden movements
– Avoid fluorescent or flickering lights
– ____________ may exacerbate symptoms
Meniere’s disease - inner ear problem that can cause dizzy spells [Vertigo] and hearing loss.
– Minimize vertigo
– Darkened quiet room
– Avoid sudden movements
– Avoid fluorescent or flickering lights
– Television may exacerbate symptoms
Acoustic Neuroma (tumor affecting ________)
– Surgical resection
CN VIII [8]
Vestibulocochlear
Benign Paroxysmal Positional Vertigo (BPPV)
– Common cause, approximately ____% of vertigo cases
– Due to free floating debris in ______________
– s/s: nystagmus, vertigo, lightheadedness, loss of balance, nausea
– No __________ loss involved
– Canalith (Epley maneuver) repositioning
– Common cause, approximately 50% of vertigo cases
– Due to free floating debris in semicircular canal
– s/s: nystagmus, vertigo, lightheadedness, loss of balance, nausea
– No hearing loss involved
– Canalith (Epley maneuver) repositioning
____________ Hearing Loss
Conditions in the outer or middle ear impair transmission of sound through air to inner ear
Causes:
– Otitis media with effusion
– Cerumen
– Perforation of tympanic membrane
– Otosclerosis
– Narrowing of external ear canal
Conductive
Conductive Hearing Loss
-Patient speaks _________ because spoken voice seems loud
-Person hears better in _______ settings
Tx:
– Treat cause
– Hearing aid
-Patient speaks softly because spoken voice seems loud
-Person hears better in noisy settings
Sensorineural Hearing Loss
-Impairment of function of the _________ ear or _________________
Causes:
– Congenital/hereditary factors
– Noise trauma
– Aging
– Meniere’s disease
– Ototoxicity (loop diuretics, ASA, NSAIDs, antibiotics, chemotherapy)
– Systemic infections (DM, bacterial meningitis, immune diseases)
-Impairment of function of the inner ear or CN VIII (vestibulocochlear nerve)
Causes:
– Congenital/hereditary factors
– Noise trauma
– Aging
– Meniere’s disease
– Ototoxicity (loop diuretics, ASA, NSAIDs, antibiotics, chemotherapy)
– Systemic infections (DM, bacterial meningitis, immune diseases)
Sensorineural Hearing Loss
-Hears sound but doesn’t understand speech
-Hearing _____________ sounds diminishes (includes consonants)
-Sounds become __________, difficult to understand
-Loss in decibel levels
Tx: hearing aid (only makes sound louder not clear)
-Hears sound but doesn’t understand speech
-Hearing high-pitched sounds diminishes (includes consonants)
-Sounds become muffled, difficult to understand
-Loss in decibel levels
Tx: hearing aid (only makes sound louder not clear)
[Audio issues] Nursing Management
Think safety!
-Consider symptoms
-Use hearing aids
-Speak slowly and avoid highpitched speech
-Write notes
-Minimize extraneous noise
-Avoid ototoxic medications
Think safety!
-Consider symptoms
-Use hearing aids
-Speak slowly and avoid highpitched speech
-Write notes
-Minimize extraneous noise
-Avoid ototoxic medications
Post-operative Care: s/p ear surgery
-Careful with sudden _________ changes
-Medicate for ____
-Instruct patient to avoid blowing nose
-If cannot control sneezing or coughing, do it with mouth open
-Avoid valsalva maneuver
-Avoid bending and lifting
-Careful with sudden position changes
-Medicate for N/V
-Instruct patient to avoid blowing nose
-If cannot control sneezing or coughing, do it with mouth open
-Avoid valsalva maneuver
-Avoid bending and lifting
[Audio issues] Health Promotion
-Environmental _______ control
-Current immunizations
––> __________ in early trimester can cause deafness
Instruct re: ototoxic medications
– Anti-malaria
– Diuretics
– Antibiotics
– Salicylates (Aspirin)
– NSAIDs
– Chemotherapeutic agents
-Environmental noise control
-Current immunizations
–– Rubella in early trimester can cause deafness
Instruct re: ototoxic medications
– Anti-malaria
– Diuretics
– Antibiotics
– Salicylates (Aspirin)
– NSAIDs
– Chemotherapeutic agents
What medication commonly causes tinnitus [ringing in ears]?
Furosemide/Lasix [diuretic]
__________ - (nearsightedness)
Myopia
Myopia is
nearsightedness
__________ - (farsightedness)
Hyperopia
Hyperopia is
farsightedness
___________ – Loss of accommodation
Presbyopia
Astigmatism
– Irregular ________________
– Light rays bent unequally
– Irregular corneal curvature
– Light rays bent unequally
Visual Corrective Options
Surgical VS non-surgical
Surgical
-Laser surgery (LASIK)
-Intraocular lens implant
Non-surgical
-Glasses, contact lenses
Right eye-
OD
Left eye-
OS
Both eyes-
OU
Photophobia
sensitivity to light
Hordeolum
Sty
A red, painful lump near the edge of the eyelid that may look like a boil or pimple.
Ptosis
drooping of the upper eyelid
Conjunctivitis
pink eye AKA swelling or inflammation of the conjunctiva
Strabismus
AKA hypertropia and crossed eyes — is misalignment of the eyes, causing one eye to deviate inward (esotropia) toward the nose, or outward (exotropia), while the other eye remains focused.
Keratitis
an inflammation or irritation of the cornea
Hordeolum (sty)
– Treat with ___________________ four times/day
– Antibiotic ointment may be indicated
– Treat with warm moist compresses four times/day
– Antibiotic ointment may be indicated
Conjunctivitis
– Control contagion
– Good ___________ to prevent spreading
– Treatment depends on type
* Mostly palliative (treat symptoms)
* Antibiotics may be prescribed
– Control contagion
– Good handwashing to prevent spreading
– Treatment depends on type
* Mostly palliative (treat symptoms)
* Antibiotics may be prescribed
Corneal Abrasion - _______ of cornea
Causes:
– Rubbing, eyelids cannot close or blinking deficit, foreign material in the eye
Prevention
– Eye lubricant (drops or ointment)
– Tape eyelids closed if patient unable to blink
– Prevent patient from rubbing eyes
Scratch of cornea
Causes:
– Rubbing, eyelids cannot close or blinking deficit, foreign material in the eye
Prevention
– Eye lubricant (drops or ointment)
– Tape eyelids closed if patient unable to blink
– Prevent patient from rubbing eyes
Intraocular Abnormalities
-Cataract
-Glaucoma
-Retinopathy
-Retinal Detachment
-Age-related Macular Degeneration
-Cataract
-Glaucoma
-Retinopathy
-Retinal Detachment
-Age-related Macular Degeneration
Cataract
-__________ of the lens
-Most _________ surgical procedure in the U.S.
-Mostly _____ related eye disorder
-Diabetic patients tend to develop cataracts at an earlier age
-Opacity of the lens
-Most common surgical procedure in the U.S.
-Mostly age related eye disorder
-Diabetic patients tend to develop cataracts at an earlier age
Clinical manifestations of Cataract
–Gradual ________ of vision
–Abnormal ________ perception
–Glaring effects
–Vision worsens at night
–Opaque lens (_______ pupil)
–Gradual decline of vision
–Abnormal color perception
–Glaring effects
–Vision worsens at night
–Opaque lens (white pupil)
Pre-operative Phase (Cataract) -
Mydriatics – ______________
NSAID drops – _______________
Cycloplegics – Anticholinergic, ________________
Mydriatics – Dilates pupil
NSAID drops – Reduce inflammation
Cycloplegics – Anticholinergic, paralyzes accommodation
Cataract Removal
Surgical - phacoemulsification & IOL
Goal of treatment to restore vision with lens implant.
* Outpatient procedure
Surgical - phacoemulsification & IOL
Goal of treatment to restore vision with lens implant.
* Outpatient procedure
Possible Complications: postoperative [cataract]
-____________________ in the eye
-Infection
-Severe pain (IOP)
-Hemorrhage
-Artificial lens damage or dislocation
-Intraocular pressure in the eye
-Infection
-Severe pain (IOP)
-Hemorrhage
-Artificial lens damage or dislocation
Following Surgery your client will need to: [eye]
-Avoid rubbing or pressing on the eye.
- Avoid activities that may increase IOP: bending, stooping, coughing, lifting.
-Eye drops as ordered.
-Antibiotics
-Anti-inflammatory
-Avoid driving until approved by ophthalmologist.
- Wear eyeglasses or an eye shield, as advised by ophthalmologist.
-Shield eye from UV rays.
-Avoid rubbing or pressing on the eye.
- Avoid activities that may increase IOP: bending, stooping, coughing, lifting.
-Eye drops as ordered.
-Antibiotics
-Anti-inflammatory
-Avoid driving until approved by ophthalmologist.
- Wear eyeglasses or an eye shield, as advised by ophthalmologist.
-Shield eye from UV rays.
Discharge instructions provided clients after eye surgery:
contact if-
Bleeding
Pain
S/S of infection
Follow-up appointment w/ ophthalmologist, usually next day
Assess home environment (i.e. assistance at home, ability to care for themselves, prevent
injury/falls)
contact if-
Bleeding
Pain
S/S of infection
Follow-up appointment w/ ophthalmologist, usually next day
Assess home environment (i.e. assistance at home, ability to care for themselves, prevent
injury/falls)
Retinopathy
- ______________ damage to retina
- Acute or gradual
- Blurs vision, progressive vision loss
- _________
– Nonproliferative - Most common
- Capillary microaneurysms, retinal swelling, and hard
exudates
– Proliferative - New blood vessel growth, hemorrhages
- ____________
– High BP creating retinal blood vessel blockage
- Microvascular damage to retina
- Acute or gradual
- Blurs vision, progressive vision loss
- Diabetic
– Nonproliferative - Most common
- Capillary microaneurysms, retinal swelling, and hard
exudates
– Proliferative - New blood vessel growth, hemorrhages
- Hypertensive
– High BP creating retinal blood vessel blockage
Retinal Detachment - Separation of retina from epithelium w/ __________________ between the two layers
Causes
– Retinal break (tears or holes)
* Can happen due to aging as the vitreous humor shrinks
* Severe myopia
* Ocular trauma or surgery
* Family or personal history of retinal detachment
Separation of retina from epithelium w/ fluid accumulation between the two layers
Causes
– Retinal break (tears or holes)
* Can happen due to aging as the vitreous humor shrinks
* Severe myopia
* Ocular trauma or surgery
* Family or personal history of retinal detachment
Clinical Manifestations of retinal tear or detachment
Retinal ___________ :
– Floaters
– Flashes (Photopsia)
– Sudden onset of blurry vision
(“cobweb, ring in visual field”)
Retinal _____________ :
– Same s/s of retinal tear
– Area of dark vision
– Painless
– Like a curtain or veil coming down
Retinal Tear:
– Floaters
– Flashes (Photopsia)
– Sudden onset of blurry vision
(“cobweb, ring in visual field”)
Retinal Detachment
– Same s/s of retinal tear
– Area of dark vision
– Painless
– Like a curtain or veil coming down
Vision Diagnostics
- Slit Lamp
- Ophthalmoscope
- Ultrasound
- Slit Lamp
- Ophthalmoscope
- Ultrasound
Vision - Treatment
– Surgery
* scleral buckle
* Vitrectomy
* Laser photocoagulation
* Cryotherapy
* Intravitreal bubble
- scleral buckle
- Vitrectomy
- Laser photocoagulation
- Cryotherapy
- Intravitreal bubble
Nursing Considerations [vision]
Positioning
– Patient may have to be face down
(intravitreal bubble)
Eye drop medications
– Antibiotics
– Anti-inflammatories
– Dilators
Pain medications
Activity restrictions
Cannot drive
Positioning
– Patient may have to be face down
(intravitreal bubble)
Eye drop medications
– Antibiotics
– Anti-inflammatories
– Dilators
Pain medications
Activity restrictions
Cannot drive
Age-related Macular Degeneration
-Most common cause of irreversible _________ vision loss
-Usually affects persons over age ___
– Nonexudative (Dry)
– Exudative (Wet)
-Most common cause of irreversible central vision loss
-Usually affects persons over age 60
– Nonexudative (Dry)
– Exudative (Wet)
Nonexudative AMD [dry]
-Most _________
-Macular cells atrophy
-Close vision affected
-Slightly blurred vision
– Difficulty reading, blind spots
– Needs more light to complete tasks
-Gradual, progressive, painless vision loss
-Most common
-Macular cells atrophy
-Close vision affected
-Slightly blurred vision
– Difficulty reading, blind spots
– Needs more light to complete tasks
-Gradual, progressive, painless vision loss
Exudative AMD [wet]
-_______ form
-Untreated leads to blindness
-Rapid onset
-Abnormal ________ near macule; Fragile, leaky
-Dry can lead to wet AMD
-Severe form
-Untreated leads to blindness
-Rapid onset
-Abnormal vessels near macule; Fragile, leaky
-Dry can lead to wet AMD
AMD Risk Factors
-Aging
-Genetic
-Cigarette smoking
-Hypertension
-Nutritional factors (vitamins C & E, Zinc, beta-carotene, lutein)
-Aging
-Genetic
-Cigarette smoking
-Hypertension
-Nutritional factors (vitamins C & E, Zinc, beta-carotene, lutein)
AMD Clinical Manifestations
-Blurred and darkened vision
-Blind spots in visual fields (scotomas)
-Vision distortion
-May not notice changes until both eyes affected
-Blurred and darkened vision
-Blind spots in visual fields (scotomas)
-Vision distortion
-May not notice changes until both eyes affected
AMD Treatment
_______________ therapy (wet AMD)
– Destroys blood vessels
– Doesn’t leave blind spot
– Very few patients eligible
– Nursing considerations
* Avoid sunlight or halogen lights (five days)
– Medications (slows vision loss)
* pegaptanib (Macugen)
* ranibizumab (Lucentis)
* bevacizumab (Avastin)
* aflibercept (Eylea)
Photodynamic therapy (wet AMD)
– Destroys blood vessels
– Doesn’t leave blind spot
– Very few patients eligible
– Nursing considerations
* Avoid sunlight or halogen lights (five days)
– Medications (slows vision loss)
* pegaptanib (Macugen)
* ranibizumab (Lucentis)
* bevacizumab (Avastin)
* aflibercept (Eylea)
Glaucoma: a group of diseases that can damage the eye’s ____________ and result in vision loss & blindness.
Cause: elevated __________________
2nd leading cause of blindness
1st among African Americans
Glaucoma: a group of diseases that can damage the eye’s optic nerve and result in vision loss & blindness.
Cause: elevated intraocular pressure
2nd leading cause of blindness
1st among African Americans
Glaucoma - anterior chamber
- Increased ___________ pressure: rate of ___________ production (inflow) exceeds the rate of absorption (outflow)
- Increased intraocular pressure: rate of aqueous production (inflow) exceeds the rate of absorption (outflow)
Primary open-angle glaucoma:
- Primary cause of _________ cases
- aqueous humor outflow is decreased due to trabecular meshwork obstruction
- Medications: adrenergics and miotics
- gradual vision loss “tunnel” vision
Primary angle-closure glaucoma:
- Angle closure causes reduced ________
- Acute occurrence
- Severe pain, frontal HAs
- Colored halos around lights
- Photophobia
- Blurred vision
- Ocular redness
- Nausea and vomiting
- True eye emergency
Primary open-angle glaucoma:
- Primary cause of glaucoma cases
- aqueous humor outflow is decreased due to trabecular meshwork obstruction
- Medications: adrenergics and miotics
- gradual vision loss “tunnel” vision
Primary angle-closure glaucoma:
- Angle closure causes reduced outflow
- Acute occurrence
- Severe pain, frontal HAs
- Colored halos around lights
- Photophobia
- Blurred vision
- Ocular redness
- Nausea and vomiting
- True eye emergency
Glaucoma-
Laser _____________
– Laser causes scarring and contraction of trabecular meshwork to open outflow
_________ surgery
– Removal of part of iris and trabecular meshwork
– Fluid percolates out through missing iris absorbed into systemic circulation
Laser trabeculoplasty
– Laser causes scarring and contraction of trabecular meshwork to open outflow
Iridectomy surgery
– Removal of part of iris and trabecular meshwork
– Fluid percolates out through missing iris absorbed into systemic circulation
Medications [Glaucoma]
Miotics – ____________
Hyperosmotic – ___________
Decrease aqueous humor production
– Alpha-adrenergic agonists
– Beta-blockers
– Carbonic anhydrase inhibitors
* Acetazolamide (Diamox)
Miotics – Constricts pupils
Hyperosmotic – Decrease IOP
Decrease aqueous humor production
– Alpha-adrenergic agonists
– Beta-blockers
– Carbonic anhydrase inhibitors
* Acetazolamide (Diamox)
Appropriate instructions for all eye patients
-Avoid sunlight
-Take prescribed medications
-Activity restrictions
-– Avoid strenuous activity
-– Avoid sudden position changes
-– Avoid bending or straining
-Wear eye cover as directed
-Return for physician’s appointment
-Avoid sunlight
-Take prescribed medications
-Activity restrictions
-– Avoid strenuous activity
-– Avoid sudden position changes
-– Avoid bending or straining
-Wear eye cover as directed
-Return for physician’s appointment
Nursing Management of clients with Visual Impairment
- Determine length of impairment
- How does impairment affect normal functioning?
- How is client coping?
- Direct eye contact when speaking in a normal tone of voice.
- Sighted-guide technique
- Explain environmental sounds, smells, etc.
- Determine length of impairment
- How does impairment affect normal functioning?
- How is client coping?
- Direct eye contact when speaking in a normal tone of voice.
- Sighted-guide technique
- Explain environmental sounds, smells, etc.
______ vision is a term used to describe impaired vision that cannot be improved by conventional eyeglasses, contact lenses, medications, or surgery in which some good usable vision remains.
________ visual impairment describes visual impairment in people who are unable to read
ordinary newsprint, even with correction. People with a severe visual impairment may or may not be legally blind.
Low vision is a term used to describe impaired vision that cannot be improved by conventional
eyeglasses, contact lenses, medications, or surgery in which some good usable vision remains.
Severe visual impairment describes visual impairment in people who are unable to read
ordinary newsprint, even with correction. People with a severe visual impairment may or may not be legally blind.
- Legal blindness refers to central visual acuity of ______ or less in the better eye with correction, or a peripheral visual field of 20 degrees or less.
20/200
HORDEOLUM
- Infection of the _____________ glands in the lid margin
- Usually caused by staphylococcus aureus
- Red, swollen, acutely tender, circumscribed area
- Treatment is warm compresses at least 4 times a day
- Infection of the sebaceous glands in the lid margin
- Usually caused by staphylococcus aureus
- Red, swollen, acutely tender, circumscribed area
- Treatment is warm compresses at least 4 times a day
_________
- Chronic inflammatory granuloma of the sebaceous gland in the lid
- Usually on upper lid, swollen, tender, red area that may be painful
- Warm moist compress to treat -May rupture, or if no spontaneous resolution an ophthalmologist may drain
CHALAZION
BLEPHARITIS - common chronic bilateral inflammation of the ____________
lid margins
Acute bacterial conjunctivitis (pinkeye) is common.
It occurs initially in one eye and can spread rapidly to the unaffected eye.
It is usually self-limiting, but __________ drops shorten the course of the disorder.
Acute bacterial conjunctivitis (pinkeye) is common.
It occurs initially in one eye and can spread rapidly to the unaffected eye.
It is usually self-limiting, but antibiotic drops shorten the course of the disorder.
A cataract is an ________ within the lens.
opacity
GLAUCOMA - Characterized by _______________________
- Second leading cause of blindness in the U.S.
- Preventable with early detection and appropriate treatment
GLAUCOMA - Characterized by increased intraocular pressure
- Second leading cause of blindness in the U.S.
- Preventable with early detection and appropriate treatment
- _________________________ is a separation of the retina and underlying epithelium with fluid accumulation between the 2 layers.
Retinal detachment
- External ______ involves inflammation or infection of the auricle and ear canal epithelium caused by infection.
otitis
Acute otitis _______is an infection of the tympanum, ossicles, and space of the middle ear.
media
Chronic _______________ - Untreated or repeated attacks of acute otitis media in early childhood may lead to chronic middle ear infection.
Otitis Media
- Ménière’s disease is characterized by symptoms of _______ ear disease.
inner
Acoustic neuroma is a unilateral _____________ that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal.
benign tumor
When educating a patient with repeated styes how to prevent further infection, which information should the RN include?
a. Apply cold compresses when you first notice symptoms.
b. Discard all open or used cosmetics applied near the eyes.
c. Wash the scalp and eyebrows with an antiseborrheic shampoo.
d. Be examined for recurrent STIs.
b. Discard all open or used cosmetics applied near the eyes.
Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using.
Your patient just had outpatient cataract surgery and lens implantation. Which discharge instruction will you expect to teach your patient?
a. The use of analgesics for pain control
b. Administration of corticosteroid eye drops
c. Importance of coughing and deep breathing exercises to prevent post op pneumonia
d. Need for bed rest for the first 1 to 2 days after the surgery to rest the eyes
b. Administration of corticosteroid eye drops
Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. P
The nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg of your patient. The nurse will plan to assess
a. visual acuity.
b. pupil reaction.
c. color perception.
d. peripheral vision.
d. peripheral vision.
The patient’s increased intraocular pressure indicates glaucoma, which decreases peripheral
vision.
Glaucoma decreases __________ vision.
peripheral
A patient with glaucoma has been using timolol drops for several days. She tells you that the eye drops cause eye burning and visual blurriness for a short time then symptoms resolve. The best response to the patient’s statement is:
a. “Those symptoms may indicate a need for an increased dosage of the eye drops so your eyes get used to the medication.”
b. “The drops are uncomfortable, but it is important to use them to retain your vision.”
c. “These are normal and expected side effects of the drug.”
d. “Notify your HCP so that different eye drops can be prescribed.”
b. “The drops are uncomfortable, but it is important to use them to retain your vision.”
Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss.
Which advice should the RN who is working with college students at the on-campus health clinic implement to decrease hearing loss?
a. Schedule otoscopic examinations for all patients during their physical exam.
b. Tell them to get their influenza vaccine.
c. Discuss the importance of limiting exposure to amplified music.
d. Perform tympanometry on all patients between the ages of 18 to 24
c. Discuss the importance of limiting exposure to amplified music.
The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods.
A patient diagnosed w/ external otitis is being discharged from the ED with an ear wick in place. Which statement by the patient indicates understanding from the discharge teaching?
a. “I will apply the eardrops to the cotton wick in the ear canal.”
b. “I can stop applying the ear drops when my ear feels better.”
c. “I will clean the ear canal daily with a cotton-tipped applicator.”
d. “I can use ice packs to the outside of the ear for comfort.”
a. “I will apply the eardrops to the cotton wick in the ear canal.”
Which action by UAP indicates that the nurse should intervene immediately when the UAP is caring for a patient with Ménière’s disease who is experiencing an acute attack
a. UAP raise the side rails on the bed.
b. UAP turn on the patient’s television.
c. UAP turn the patient to the right side.
d. UAP place an emesis basin at the bedside.
b. UAP turn on the patient’s television.
Which nursing action will the nurse include in the plan of care for a 30 year-old male patient admitted with an IBD flare up?
a. Restrict oral fluid intake.
b. Monitor stools for blood.
c. Ambulate six times daily.
d. Increase dietary fiber intake
b. Monitor stools for blood.
The nurse would increase the comfort of the patient with appendicitis by:
A. Having the patient lie prone
B. Flexing the patient’s right knee
C. Sitting the patient upright in a chair
D. Turning the patient onto his or her left side
B. Flexing the patient’s right knee
A patient has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight loss of 10 lb over the last 2 months. The nurse will plan to teach about:
a. medication use.
b. fluid restriction.
c. enteral nutrition.
d. activity restrictions.
a. medication use.
Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of:
A. Impaired peristalsis
B. Irritation of the bowel
C. Nasogastric suctioning
D. Inflammation of the incision site
A. Impaired peristalsis
Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention.
Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn’s disease (select all that apply)?
A. Restricted to rectum
B. Strictures are common
C. Bloody, diarrhea stools
D. Cramping abdominal pain
E. Lesions penetrate intestine
C. Bloody, diarrhea stools
D. Cramping abdominal pain
What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy?
A. How to care for the wound
B. How to cough and deep breathe
C. The location and care of drains after surgery
D. Which medications will be used during surgery
B. How to cough and deep breathe
Because anesthesia, an abdominal incision, and pain can impair the patient’s respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery.
When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?
A. White bread, cheese, and green beans
B. Fresh tomatoes, pears, and corn flakes
C. Oranges, baked potatoes, and raw carrots
D. Dried beans, All Bran (100%) cereal, and raspberries
D. Dried beans, All Bran (100%) cereal, and raspberries
A high-fiber diet is recommended for diverticular disease
When evaluating the patient’s understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching?
A. “I will be able to regulate when I have stools”
B. “I will be able to wear the pouch until it leaks”
C. “The drainage from my stoma can damage my skin”
D. “Dried fruit and popcorn must be chewed very well”
A. “I will be able to regulate when I have stools”
An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
A. Leukopenia with a shift to the left
B. Leukocytosis with a shift to the left
C. Leukopenia with a shift to the right
D. Leukocytosis with a shift to the right
B. Leukocytosis with a shift to the left
Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells)
The nurse is caring for the patient with acute appendicitis. Which interventions will the nurse perform? (select all that apply)
A. Maintain the patient on NPO status
B. Administer IV fluids as prescribed
C. Apply warm compresses to the right lower abdominal quadrant
D. Maintain the patient in the supine position
E. Administer laxatives
A. Maintain the patient on NPO status
B. Administer IV fluids as prescribed
Which of the following conditions is most likely to directly cause peritonitis?
A. Cholelithiasis
B. Gastritis
C. Perforated ulcer
D. Incarcerated hernia
C. Perforated ulcer
The most common cause of peritonitis is a perforated ulcer, which can pour contaminates into the peritoneal cavity, causing inflammation and infection within the cavity.
Which of the following aspects is in the priority focus of nursing management for a client with peritonitis?
A. Fluid and electrolyte balance
B. Gastric irrigation
C. Pain management
D. Psychosocial issues
A. Fluid and electrolyte balance
Peritonitis can advance to shock and circulatory failure, so fluid and electrolyte balance is the priority focus of nursing management
Which of the following definitions best describes diverticulosis?
A. An inflamed outpouching of the intestine
B. A noninflamed outpouching of the intestine
C. The partial impairment of the forward flow of intestinal contents
D. An abnormal protrusion of an organ through the structure that usually holds it
B. A noninflamed outpouching of the intestine
Diverticulosis involves a noninflamed outpouching of the intestine.
Diverticulitis involves an inflamed outpouching
