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Adult Health I Final
Terms in this set (65)
A sign of a UTI in the elderly is:
confusion, b/c the nerve cells of the elderly decrease.
Chain of infection:
1. Etiological agent
3. Portal of exit from reservoir
4. Method of transmission
5. Portal of entry
6. Susceptible Host
The nurse providing care for a pt who is diagnosed w stress incont. Which data would the nurse expect to collect during the pts hist. and phys. assess.? SATA
Urine leaking while coughing; Urine leaking while laughing; Skin breakdown on the buttock.
Stress incont. involves:
a small leakage of urine when a pt laughs, coughs, or lifts something heavy.
A pt w incont. would:
wear some kind of undergarm. pad.
If a pt is experiencing incont. the nurse might see:
the skin inflamed/irritated b/c urine is very irritating to skin.
The nurse @ a health fair is educat. pts on the risk factors assoc. w urinary incont. Which risk fact. does the nurse include as a nonmodifiable risk fact. for urin. incont.?
Obesity, smoking, diabetes, inactivity & depression are all:
modifiable risk fact. for urinary incont.
A pt in the ambul. care clin. tells the pt about exper. freq. constip. The nurse inquires abt the pts diet. Which statement from the pt would be greatest concern for the nurse?
"I like to eat cheese, a banana, & a turk. sandwich for lunch.
Both cheese and bananas are:
constipating foods that should be limited.
The charge nurse is obs. a nursing stud. conduct an abd. assess. on a pt with an abd. mass that is affecting the bowel elim. Which actions by the stud. would require the charge nurse to interv.?
Using deep palp. during the assess. process.
Physical exam. of the abd. in relation to bowel elim. probs. includes:
inspection, auscultation, percussion & palp.
Never use deep palp. on a pt w:
an abd. mass, renal trans., or polycystic kidneys or pts @ risk for hemmorrhage.
The nurse is interv. a pt who is exper. constipat. During the interv. the pt states "I don't under. what is going on. I feel the urge to go to the bathroom but, once I'm there & begin to push w abd. muscs. nothing happens." Which is the nurses best response?
"Try to avoid straining w abd. muscs. during defecation. Doing so may actually close the anal sphincter, prev. feces from passing.
The nurse is caring for a pt. who uses cathartics freq. Which state. made by the pt. indic. an understanding of disch. teach.?
"I don't have to have a bowel movement every day."
You are taking care of a pt exper. diff. & strain. when expelling feces. Which interv. should be taught to the pt?
Enc. the pt to eat a high-residue diet.
A high-residue diet provides bulk for the:
colon to use in removing the waste products of metabolism.
Oxybutynin chloride (Ditropan) is prescribed for a pt w a neurogen. bladd. Which sympts. would indic. a poss. toxic eff. r/t this med? SATA
Irrit., Halluc., Hypotens., Restless., Resp. Dist.
Toxicity (OD) of oxybutynin produces CNS implications such as:
Nerv., restless., halluc., irrit., hypotens./hypertens., conf., tachycard., flushed, red face, & resp. depress.
The nurse is develop. a teach plan for a pt w stress incont. Which of the follow. instructs. should be included?
Avoid caff. & alc.
Aft. performing an initial abd. assess. on a pt, the nurse doc. that bowel sounds are norm. Which of the following descripts. best describes this assess. finding?
Soft gurgling sounds or clicking auscultated in all 4 quadrants.
The nurse is develop. a care plan for an older pt being admit. to a long-term care fac. Approp. info. to remem. when plan. indep. nursing interven. for this pt are which of the follow.? SATA
Older pts are at risk for dehyd., age-related skin changes require special mon., older pts are @ risk for complica. of immobility.
One of the norm. physiolo. changes that occur during aging is:
loss of skin integ.
Older pts are @ risk for:
dehydr., incont., depress., conf., & cogn. changes.
The pt has dark, watery & shiny-appear. stool. Which indep. nurs. interv. should the nurse imple. first?
Check for fecal impact.
Pts experienc. diarrhea should have which lab checked?
The female pt came to the clinic compl. of abd. cramps & 10 episodes of diarrhea for the last 2 days. The pt just returned from a trip to Mex. Which indep. nurs. interv. should the nurs. implem.?
Enc. the pt to drink lots of Gatorade.
The nurse is caring for a female pt experi. urinary incont. Which indep. nurs. interv. should the nurse imple.? SATA
Turn on the water or flush the toilet to assist the pt. to void, Avoid caff. & foods or bev. that may cause bladd. irrit.
The nurse is instruc. a newly diagnos. pt w DM2 on the s/s of hypogly. Which of the follow. should the nurse include in the instruct.? SATA
Blurred vis., mood swings, HA, Excess. thirst, weak/fat.
A pt asks what DM does to the body over the time. Which cond. should the nurse include in teach. as a common chronic complic. of DM?
The nurse receives the follow. order for insulin IV NPH (Humulin NPH) 10 units. The nurs will perform which act. first?
Clarify the insulin type & route.
The only insulin given IV is:
The nurse teaches a pt w DM who is exper. numb. & reduced sens. in the lower extrem. Whic state. should the nurse include in this pts teach. to prev. injury?
"Use a bath thermometer to test the water temp."
Pts w diminished sens. percept. can easily exper. a:
burn injury when bathwater is too hot.
A nurse performs a phys. assess. on a pt w type 2 DM. Find. include FBS of 120 mg.dl; temp. of 101 F; pulse of 88; RR of 22; & BP of 122/78. Which find. would be of most concern?
The insulin that has the most rapid onset of action would be:
Lispro has an onset, peak and duration of:
O-0.25 hrs, P-1-1.5 hrs, & D-3-4hrs.
Which of the follow. chron. complic. is assoc. w diabetes?
Retinopathy, neuropathy, & coronary artery disease.
A pt who has been taking a sulfonylurea antidiabetic med will begin taking Metformin (Glucophage). The stud. nurs. understands that this pt is at incr. risk for which cond.
A pt. dev. type 2 DM. The nurse instr. will expl. that this type of diabetes is:
often r/t heredity & obesity.
A stud. nurse teaches a pt w DM about sick day manag. Which statement should the stud. nurse include in the teach.?
"Mon. your blood glucose levels at least every 4 hrs while sick."
A stud. nurse is prov. diab. educa. at a publ. health fair. Which disord. should the stud. include as a compl. of diabetes? SATA
Stroke, Kidney failure, Blindness.
Complication of DM are caused by:
macrovascular & microvascular changes.
Macrovascular complic. include:
coronary artery disease, cerebrovasc. disease, & peripheral vasc. disease.
Mircrovascular complic. include:
nephropathy, retinopathy, & neuropathy
The nurs. stud. is complet. an assess. inter. w an older adult pt. being seen for a yearly physic. exam. Which pt state. would indic. a poss. diagn. of DM?
"I've been exp. increased thirst during the past sev. months."
A pt who was involved in a motor vehicle crash had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mmHG, PaCO2 32 & HCO3 25 mEq/L?
A pt is suspected of having severe hypocalcemia. While waiting for the pt's serum electrolyte results, the nurse will assess for which symptoms? SATA
Laryngeal spasms, twitching of the mouth, & numbness of the fingers.
The nurse is caring for a pt who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
Encourage fluid intake up to 4,000 mL every day.
A pt is recieving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are crackles throughout the lung fields, b/c of pulmonary edema.
A pt has been admitted w chronic obstructive pulm. disease. Diag. tests have been ordered. Which of the tests will provide the most accurate indicator of the pt's acid-base balance?
The nurse is caring for a comatose pt w metabolic acidosis. For which intervention will the nurse need to collaborate when caring for this pt?
The pt's recent eating behaviors
A home health nurse is providing care for a pt diag. w/ HF. The pt is taking furosemide (Lasix). The nurse reviews the pts most recent serum potass, which was 3.4 mEq/L. Based on this data, which food should the nurse enc. the pt to consume?
A pt is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The pts current wt is 154 pounds. The HCP has diag. the pt w a viral infect. The nurse has been mon. IV fluids & UO. Which UO should indicate that efforts to rehydrate this pt have been successful?
40 mL per hr
The nurse is caring for an older adult pt who is recieving IV fluids @ 150 mL/hr. Upon assess., the nurse notes crackles, shortness of breath, & jugular vein distention. Based on this data, which compl. of IV fluid therapy does the nurse anticipate?
Fluid volume excess
The nurse receives a shift report on a pediatric med-surg unit. The nurse has been assigned four pts for the shift. Which pt should the nurse plan to assess first based on an increased risk for dehydration?
A 15-month-old child tachypnea.
Metoclopramide is a:
Zofran is a:
Before surgery we get vital signs
to compare to the VS after surgery.
is the time for blood to clot -plasma
Hypertension Stage 1:
Hypertension Stage 2
(Syst. BP + (2) Dias. BP)/3
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