NUR 216 Exam 3

bereavementperiod of mourning and adjustment after lossuncomplicated griefnormal grief, natural response to a loss; acknowledgement of loss but the intensity of the response to the loss will lessen overtimeanticipatory griefa syndrome characterized by the presence of grief in anticipation of death or loss; the actual death comes as a confirmation of knowledge of a life-limiting condition ex: wife caring for husband's long term illnesschronic griefbegins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal lifedelayed griefgrief that is put off until a later timemasked griefbehaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss and ineffective grief resolution ex: alcohol overtime can turn to alcoholism leading to disruptive behavior and interactions with family members and friendsdisenfranchised griefwhen your grieving doesn't fit in with your larger society's attitude about dealing with death and loss ex: man or woman that has been involved in an affair that has lost their partnerstages of grief: engel1. shock and disbelief 2. developing awareness 3. restitution 4. resolving the loss 5. idealization 6. outcomestages of grief: worden ***1. accept the reality of the loss 2. work through the pain of grief *** longest stage to go through *** 3. adjust to the environment in which the deceased is missing 4. to find an enduring connection while embarking on a new lifestages of grief: kubler-ross***1. denial 2. anger 3. bargaining 4. depression 5. acceptancefactors influencing grief and loss1. age 2. gender 3. closeness to the passed loved one 4. family support 5. culture and ethnicity 6. religious beliefs 7. nature of the loss: expected or suddendiverse cultures related to death and lossdiverse ritual changes within cultures ex: Day of the Dead- believing that their deceased loved ones come back from the dead to join in the celebration of Day of the Deadpsychological stages of dyingkubler-ross model: 1. denial 2. anger 3. bargaining 4. depression 5. acceptancephysiological stages of dying* patient may experience burst of energy before passing: 1 to 3 months prior to death 1 to 2 weeks prior to death Days to hours prior to death Moments prior to deathpalliative carecare that helps patients deal with symptoms; not end of life carehospice carecare that focuses on the patient's quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness; end of life care; >6 monthsfunction of lifebancdedicated to saving and healing lives through organ, eye, and tissue donation and transplantationcompassion fatigueloss of satisfaction from providing good patient care; experienced by nurses and healthcare professionals who deal with a lot of deathNANDA for patients and family member with a lossterminal illness: anticipatory grieving r/t perceived potential death of patient, AEB bargaining, expression of fear of death, low mood, loss of appetite, and inability to sleepnursing interventions for patients and family members with a loss: terminal illness1. open-ended questions 2. reassurance 3. assessing the stage of grief in which the patient or family members are in 4. allow and encourage the patient to make independent choices regarding their care 5. involve the family members in the patient's care and planning to allow for closure 6. refer the patient to palliative or hospice carescheduled medication ordersmedications given on a continuous, around-the-clock schedule; 9pm, 10pm, 11pmstanding ordersdefinitive set of treatment guidelines that include said definitive orders for drugs and specific orders until changed or cancelled; immunizations, health screenings, refill on a prescription ex: O2 ordersstat ordersingle order carried out immediatelyone-time order (once)order of medication given only onceas needed order (PRN)order of medication given to a patient as needed ex: morphine 2mg every 6 hours as needed6 rights of medication administration for patients/clients1. right patient 2. right medication 3. right dose 4. right time 5. right route 6. right documentation3 points for medication checks1. obtaining medication 2. assess the patient and checking wristband 3. scanning in the medicationsome ways to identify an incorrect medication order1. chart review 2. computerized monitoring 3. admin database 4. direct observation 5. incident reporting 6. patient monitoring 7. claims datafactors influencing urination1. muscle tone 2. surgical procedures 3. neurological issues 4. psychosocial issues 5. meds 6. age 7. exercise 8. diet 9. gendercommon urinary problems1. UTI; CAUTI 2. urinary retention 3. urinary incontinenceilleal conduit (urinary diversion)a new passage created to divert urine to exit the body through a small opening called a stomaindiana pouch (urinary diversion)type of urinary diversion in which the ascending colon and cecum are made into a pouch, with the ileum pulled through the urostomy and sewn into the outside of the belly then forming a stomaneo-bladder (studder pouch) (urinary diversion)surgical procedure to construct a new bladderNANDA for patients with alteration in urinary problemsimpaired urinary elimination r/t UTI AEB hesitancy and burning while urinatingnursing interventions for patients with alteration in urinary problems1. begin bladder retaining per protocol when appropriate 2. encourage adequate fluid intake, avoiding caffeine, and limiting intake during late evening and at bedtime 3. observe for cloudy/bloody urine/foul odor 4. promote continued mobility 5. teach Kegel exercisessigns and symptoms UTI1. burning when you pee (dysuria) 2. strong urge to urinate 3. passing frequent, small amounts of urine 4. urine appears cloudy 5. having to pee more frequently during the night (nocturia)factors influencing bowel elimination1. age 2. diet 3. exercise 4. drugs 5. fluids 6. disability 7. surgery/procedurecommon bowel elimination problems1. constipation 2. impaction 3. diarrhea 4. incontinence 5. flatulence 6. hemorrhoidshow to identify alterations in bowel elimination1. change in frequency 2. change in consistency 3. caliber of the stoolsileostomynew opening of the ileum to the outside of the body; stoma is presentcolostomyremoval of a diseased portion of the colonkock pouch (k-pouch)continent pouch formed by the terminal ileum after a colectomy; creation of an internal pouch from a section of the small intestine; often a treatment for a patient with UC where medical management has failedileo-anal reservoir (j-pouch)surgery that removes parts of the large intestine; often done to treat UC and other diseases in which the patient has a high risk of colon and rectal cancerwhat does a bowel elimination consist of asses of stomaevery 6 hours empty pouch half full if any problems; consider continence nurse normal saline is a good agent to irrigate the woundNANDA for patients with alteration in bowel problemsbowel incontinence:what should a patient achieve every time they sleepREMhow would you encourage sleep and rest in the hospitalcluster the patient's care, especially at nightwhat are the stages of sleep1. less than 10 minutes, begins right after falling asleep 2. lasts anywhere from 30 to 60 minutes 3. lasts between 20 to 40 minutes 4. about 10 minutes for the first period during sleep, then increasingly longer with later periodssleep cyclestage 1: light sleep; can be easily awakened stage 2: eye movement and brain waves slowing down stage 3: delta waves begin to appear stage 4: deep sleep; difficult to wake up REM: breathing becomes more rapid and irregularfunctions of sleep1. memory consolidation 2. energy conservation 3. helps restore bodily functionseffects of physical illness on sleep1. insomnia: patient cannot sleep or sleeps during the day instead of at night 2. restless leg syndrome (RLS): patient cannot fall or stay asleep due to uncontrollable leg movements 3. hypertensionpressure ulcerstissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosiswound healingprimary: secondary: tertiary:stages of pressure ulcers1. red and intact skin; nonblanchable erythema 2. skin broken or blistered, superficial loss 3. skin broken and deeper loss, deep crater 4. skin broken and deep tissue loss, massive crater muscle and bone are visibledehiscencebursting open of a wound, especially a surgical abdominal woundeviscerationthe displacement of organs outside of the bodyserousclearserosanguineousPale, pink, watery; mixture of clear and red fluidsanguinousbloodypurulentpusPUSH scale for wound healingmeasuring the wound length x width x depth; multiply the length and width to obtain an estimate of surface area in square centimetersuse of braden scale to assess skin breakdownthe use of scores from <9 to as high as 23; the lower the number the lower the riskJP drainsbulb suction, always release suction when taking outto promote proper wound healing1. moisture balance: for cellular deposition/migration 2. warmth: adequate blood flow 3. protection against injury and infection7 principles for wound healing1. dry: provide moisture 2. moist: maintain the moisture 3. wet: absorb the excess 4. cool: insulate it (increases perfusion) 5. necrotic: debride it 7. stalled from healing: provide nutritional support/change therapywound VAC (WVAC)a type of negative pressure wound therapy; vacuum assisted closure of a wound and promote healingblack foammore protective of the healing of the wound bedwhite foamoften indicates infection and needs treatment as soon as possibleventilationmovement of air in and out of the lungsperfusionthe supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillariesdiffusionthe spontaneous movement of gases, without the use of any energy or effort by the body, between the alveoli and the capillaries in the lungsHypoventilationdecreased rate or depth of air movement into the lungs; overload of CO2hyperventilationincreased rate and depth of breathing; overload of O2hypoxialack of oxygenhypercapniaexcessive carbon dioxide in the bloodhypoxemiadecreased level of oxygen in the bloodcyanosisbluish discoloration of the skinCOPDchronic obstructive pulmonary disease; lung disease that is commonly seen in smokersemphysemacondition in which the air sacs of the lungs are damaged and enlarged; causing SOB, cough, rapid breathing, wheezing, etc.pneumoniabacterial inflammation of the lungspulmonary edemafluid in the lungspulmonary embolusblockage of the pulmonary artery or one of its branches due to a translocated clottraumawound or injuryanemiaRBC deficiencynasal cannulaa device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils; 1-4L without hydration, >5 requires hydrationsimple mask35-50% FIO2, 6-10L, no hydrationnon-rebreather maskup to 90% FIO2, 10-15L, no hydrationventuri maskcolored connectors to the tube that connects to the mask, the order given by the doctor shows how much O2 should be administered; FIO2 goes from 2-15L; no hydrationatelectasiscollapsed lungbradypneaabnormally slow breathing; usually <12 breaths per minutetachypnearapid breathingkussmaul breathingrapid, deep, labored; considered regular breathing when a patient is in diabetic ketoacidosis or has kidney diseasecheyne-stokes breathingperiodic and irregular breathing; seen when a patient is close to dying, SOB when sleepingcontinuous positive airway pressure (CPAP)delivers an inhale pressure; provides air at a pressure just high enough to prevent the collapse of your airway; pressurized air is provided through a mask that seals with your mouth or nose; used in patients with sleep apneabilevel positive airway pressure (BiPAP)delivers an inhale and exhale pressure within the lungs; used with patients that have sleep apnea, COPD, asthma, & heart conditionsCBC with differential labsA lab test measuring the total number of WBCs, that has monocytes, lymphocytes, granulocytes, neutrophils, eosinophils, basophilsCMP labscomprehensive metabolic panel; measures 14 different substances in your bloodhepatic panelALP, ALT, AST, bilirubin total and direct, total protein, albumin labsBMP labsblood test that gives information about the body's fluid balance, levels of electrolytes (NA+ & K), and how well the kidneys are workingrenal panelkidney function tests for blood urea nitrogen, creatinine, uric acid, electrolytesBNP labsblood test measuring the levels of a protein (BNP) that is made by your heart and blood vesselsurinalysisthe examination of urine to determine the presence of abnormal elementsstool sample: ova and parasitesmost people who are infecting by GI parasites become infected by drinking water or eating foods that have been contaminated with the ovaoccult bloodfecal occult blood test (FOBT) is a lab test used to check stool samples for hidden blood also known as:___________; these may indicate colon cancer or polyps in the colon or rectumculture for urine and bloodbacteria culture test that can find harmful bacteria in your bodyCXRchest x-raymagnetic resonance imaging (MRI)non-invasive imaging test done produce detailed images of almost every internal structure in the human body including organs, bones, muscles, and blood vesselscomputed tomography (CT)head: helps to assess head injuries, sever headaches, dizziness, and other symptoms of aneurysms, bleeding, stroke, and brain tumors chest: used to examine abnormalities to help diagnose the cause of an unexplained cough, SOB, chest pain, fever, and other chest related symptoms abd/pelvis: used to detect diseases of the small bowl, colon, and other internal organsendoscopyvisual examination of a body cavity or canal using a specialized lighted instrument called an endoscope; goes in through the mouthintravenous pyleogram (IVP)x-ray exam of kidneys, ureteters and urinary bladdersigmoidoscopyvisual examination of the sigmoid coloncolonoscopythe direct visual examination of the inner surface of the entire colon from the rectum to the cecum; goes through your buttKUB (flat plate of abdomen)(kidneys, ureters, bladder) is a radiographic study of these structures without the use of a contrast medium; used to assess the abd area for causes of abd pain/ assess the organs and structures of the urinary or GI systemcystoscopythe visual examination of the urinary bladder using a cystoscopeThe female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as A. Stress incontinence B. Urge incontinence C. Functional incontinence D. Unconscious incontinenceA. Stress incontinenceThe nurse prepares to insert an indwelling urinary catheter. Which statement least explains the reason for this intervention? A. Empty your bladder prior to your procedure. B. Treat your problem of leaking urine. C. Obtain a sterile urine specimen for culture. D. Measure the amount of urine left after you emptied your bladder.B. Treat your problem of leaking urine.There is a 24-hr urine collection in process for a client. The unlicensed assistive personnel (U A P) inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should A. Continue with the collection of urine until the 24-hr time period is finished. B. Make a note to the lab to inform them that one specimen was missed during the collection. C. Begin filling a new collection container and take both containers to the lab at the end of the collection period. D. Dispose of the urine already collected and begin an entirely new 24-hr collection.D. Dispose of the urine already collected and begin an entirely new 24-hr collection.The nurse knows that the results of a fecal occult blood test can be inaccurate if A. The client has had an excessive intake of red meat. B. The female client is menstruating. C. The client takes high doses of vitamin C. D. All of the above.D. All of the above.Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years." Which nursing diagnosis is most appropriate for the nurse to use in her plan of care? A. Diarrhea B. Constipation C. Risk for Ineffective Therapeutic Regimen D. Perceived ConstipationD. Perceived ConstipationYou are caring for a patient with a colostomy. In order to provide safe care you understand that when irrigating a colostomy a proper fitting cone is needed to prevent A. Introducing air into the colon B. Leaking the solution around the stoma C. Administering the solution too rapidly D. Introduction of bacteria from the stomaB. Leaking the solution around the stomaThe nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is A. "I'm sure you will get used to taking care of it eventually." B. "Yes, it is pretty messy, so I'll take care of it for you today." C. "It sounds like you are really upset." D. "You sound very angry. Should I call the chaplain for you?"C. "It sounds like you are really upset."Light sleep and slowing brain and body processes are associated with which stage of N R E M sleep? A. N R E M I B. N R E M II C. N R E M III D. R E MB. N R E M IIThe nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is A. "You are sleep deprived, but that will resolve in a few days." B. "You are experiencing hypersomnia, so it will be important for you to walk in the hall more often." C. "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" D. "I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep."C. "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"For which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care? A. Snoring B. Enuresis C. Narcolepsy D. HypersomniaC. NarcolepsyOf the following factors, which would put a client at greatest risk for impaired skin integrity? A. Medication, digoxin B. Moisture C. Decreased sensation D. DehydrationC. Decreased sensationThe client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to A. Notify the surgeon STAT. B. Place a clean, sterile 4 × 4 over the incision and monitor the drainage. C. Wrap an Ace bandage firmly around the area and have the client maintain bedrest. D. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.B. Place a clean, sterile 4 × 4 over the incision and monitor the drainage.The client has a wound that is 0.4 cm long and 3.2 cm wide. There is only a light amount of exudate, and granulation tissue is seen. The "PUSH" score for this would be A. 9 B. 18 C. 15 D. 22A. 15; 2 length × 6 width = 12 Exudate = 1 Granulation = 2 Total = 15 pointsThe student nurse has earned "A's" in all of her prerequisite courses. For the first exam in a nursing course, she earns a "D" and now feels that she may not be smart enough to become a nurse. What type of "loss" is the student experiencing? A. Actual B. External C. Physical D. PerceivedD. PerceivedA young woman's fiancé died in a car accident one month prior to their wedding day. Since his death, she has become sexually promiscuous. What type of grief, if any, is the woman displaying? A. Chronic B. Disenfranchised C. Masked D. No griefC. MaskedYour 55-year-old patient was just informed that she has metastatic pancreatic cancer and has 4 months to live. After the provider leaves, she says to you, "I don't want my family to know. But they have to know. Please don't tell them. Please tell me what to do, help me." What is your best response? A."I know this is difficult for you. Take time to think about it." B."You should get a second opinion before you alarm your family." C."Let me hold your hand to make you feel better." D."Tell me how you are feeling right now."A."I know this is difficult for you. Take time to think about it."The client is dying of cancer and can no longer swallow. The son states to the nurse, "You MUST give dad some water, he always drank a lot of water." The nurse's best response is A."You sound very upset. Tell me more about your dad." B."Your father is dying from cancer and water will not stop this process." C."Research shows that withholding oral fluids decreases edema." D."I will call the provider and get a prescription to insert a nasogastric tube for the water."A."You sound very upset. Tell me more about your dad."The client has been on a low-protein diet. This will most likely affect which pharmacokinetic process? A. Absorption B. Excretion C. Distribution D. MetabolismC. DistributionThe nurse is having difficulty deciphering the medication prescription written by the provider. What is the best strategy to clarify the information? A. Ask the patient what medication the provider prescribed. B. Call the pharmacist and ask him or her to read the prescription. C. Ask the nurse who knows the provider's handwriting to read the prescription. D. Call the provider and ask him or her to clarify the prescription.D. Call the provider and ask him or her to clarify the prescription.When administering a drug via a parenteral route, the drug would be absorbed fastest if given per the intramuscular (IM) route. A. True B. FalseB. FalseWhich diagnostic test/exam would best measure a client's level of hypoxemia? A. Chest x-ray B. Pulse oximeter reading C. Arterial blood gas (A B G) sampling D. Peak expiratory flow rateC. Arterial blood gas (A B G) samplingThe term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. A. True B. FalseB. FalseA nurse is teaching her client how to obtain a sputum specimen. In order to provide safe and effective care, the nurse instructs the patient that the following action will facilitate obtaining the specimen? A. Limiting fluid intake B. Having the client take deep breaths C. Asking the client to spit into a collection container D. Suggesting to the client that the specimen be obtained after eatingB. Having the client take deep breathsIn caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of A. Risk for Ineffective Airway Clearance B. Anxiety Related to Suctioning C. Social Isolation Related to Altered Body Image D. Impaired Tissue IntegrityA. Risk for Ineffective Airway Clearance