Nursing Study Guide Answer Key

Potter & Perry: Fundamentals of Nursing, 7 th Edition Study Guide Answer Key Chapter 1: Nursing Today

a. b. b. c. d. e. a. b. c. d. e.

1. the protectio protection, n, promotion promotion and optimiz optimization ation of health health and abilit abilities, ies, preventi prevention on of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and populations. 2. the role role of nursing nursing as being in in charge of a client’ client’ss health based based on the knowledge knowledge of how to put the body in such a state as to be b e free of disease or to recover from disease. 3. d 4. c 5. b 6. a 7. Demographic Demographic changes changes (rural (rural areas areas to urban urban centers, centers, increased increased life life span, higher higher incidence of chronic long-term illness, increased incidence of alcoholism and lung cancer). Women’s health care issues (new specialties). Human rights movement (minorities, terminal illness, pregnant women, older adults). Medically underserved (poor and on Medicaid, working poor, mentally ill with little to no access to health care). Threat of bioterrorism (nuclear, chemical or biological). 8. Rising Rising health health care costs costs (challenge (challenge is to to use health health care and client client resource resourcess wisely). Evidence-based practice (a problem-solving approach to clinical practice that uses the best available evidence along with your expertise and client preferences and values in making decisions about care). Nursing and biomedical research. Nursing shortage (global). 9. A prof profes essi sion on requi equire ress an an ext exten ende ded d edu educa cati tion on of its mem member bers as as wel welll as as a bas basiic liberal foundation. has has a theor heoret etiical cal bod body y of of kno knowl wled edge ge lead leadiing to defi define ned d ski skillls, abi abiliti ities, es, and and norms. provides a specific service. has autonomy in decision making and practice has a code of ethics for practice 10. Assessment Diagnosis outcome identification planning implementation Evaluation 11. Quality of practice, education, professional practice evaluation, collegiality, collegiality, collaboration, ethics, research, resource utilization, leadership

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Study Guide Answer Key

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12. the philosophical ideals of right right and wrong that define the principles principles you will use to provide care to your clients 13. c 14. d 15. b 16. e 17. a 18. g 19. f 20. To protect public health, safety, and welfare 21. Novice, advanced beginner, competent, proficient, expert 22. b 23. d 24. n 25. g 26. c 27. f 28. m 29. i 30. k 31. j 32. l 33. h 34. e 35. a 36. o 37. 3. Nursing is a combination combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies. 38. 2. Candidates are eligible to take take the NCLEX-RN to become registered registered nurses in the state in which they will practice. 39. 2. The ANA’s purpose is to improve the professional professional development and general welfare of nurses.



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12. the philosophical ideals of right right and wrong that define the principles principles you will use to provide care to your clients 13. c 14. d 15. b 16. e 17. a 18. g 19. f 20. To protect public health, safety, and welfare 21. Novice, advanced beginner, competent, proficient, expert 22. b 23. d 24. n 25. g 26. c 27. f 28. m 29. i 30. k 31. j 32. l 33. h 34. e 35. a 36. o 37. 3. Nursing is a combination combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies. 38. 2. Candidates are eligible to take take the NCLEX-RN to become registered registered nurses in the state in which they will practice. 39. 2. The ANA’s purpose is to improve the professional professional development and general welfare of nurses.



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Chapter 2: The Health Care Delivery System

1. 2. 3. 4. 5. 6. 7. 8. 9.

b f a e c d h g Primary Primary care care focuses focuses on health health services services that are are provided provided on an individual individual basis basis while while primary health care focuses on improved health outcomes for an entire population. 10. work work redesi redesign gn 11. case management management 12. The nurse coordinates the efforts efforts of all disciplines disciplines to achieve the most efficient efficient and appropriate plan of care for the client. 13. Discharge Discharge planni planning ng 14. is a multidisciplinary multidisciplinary treatment plan that shows shows what treatments or interventions clients need to have while in the hospital for a specific reason 15. a. safe and effective use of medications b. b. inst nstruct ructio ion n and and coun counse selling ing on food food-d -dru rug g int inter erac acti tion ons, s, nut nutrriti ition, on, and and mod modiified fied diets c. rehabilitation techniques d. access to appropriate co community resources e. when and how to obtain further treatment f. the resp respon onsi sibi billities ties of the clie client nt and and the the fam famiilies lies wit with ong ongoi oing ng heal healtth car caree needs 16. is to help individuals regain regain maximal functional status and to enhance quality of life life through promotion of independence and self-care 17. wound care, respiratory care, monitoring monitoring of vital signs, elimination care, nutrition, rehabilitation, monitoring compliance of medications, blood glucose monitoring 18. rehabilitat rehabilitation ion 19. extensive supportive care until they they are able to move back into the the community or into a residential-care facility 20. minimum data set (MDS), (MDS), resident assessment protocols (RAPs), utilization utilization guidelines of each state 21. d 22. c 23. a 24. b 25. the integration of best research research evidence with clinical expertise and patient patient values 26. Quality Quality improvement improvement (QI) (QI) 27. nursing-sen nursing-sensiti sitive ve outcomes outcomes 28. a. respect values, preferences, and needs



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b. coordination and integration of care c. information, communication, and education d. physical comfort e. emotional support f. involvement of family and friends g. transition and continuity 29. 4. Activities that develop human attitudes and behaviors to maintain or enhance well being 30. 1. initially focuses on the prevention of complications related to the illness or injury. Once the condition stabilizes, rehabilitation helps to maximize the client’s level of independence. 31. 2. where they receive supportive care until they are able to move back into the community 32. 1. focus is palliative care, not curative treatment



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Chapter 3: Community-Based Nursing Practice

1. focuses on primary rather than institutional or acute care and provides knowledge about health and health promotion and models of care to the community 2. gathering information on incident rates for identifying and reporting if new infections or diseases, adolescent pregnancy rates, MVAs by teenage drivers 3. a. focus requires understanding the needs of a population (e.g., high-risk infants, older adults, or cultural groups) b. is a nursing practice in the community, with the primary focus on the health care of individuals, families, and groups in the community 4. in community settings such as the home or a clinic, where the focus is on the needs of the individual or family 5. a. the inner circle of the client and the family b. people and settings that have frequent contact with the client and family c. local communities’ values and policies d. larger social systems 6. a. clients who are more likely to develop health problems as a result of excess risks b. who have limits in access to health care services c. are dependent on others for care 7. access to health care is limited because of lack of benefits, resources, language barriers, and transportation 8. live in hazardous environments, work at high-risk jobs, eat less nutritious foods, have multiple stressors 9. mental health problems, substance abuse, socioeconomic stressors, dysfunctional relationships 10. socioeconomic problems result from financial strain of the cost of drugs, criminal convictions, communicable diseases, and family breakdown 11. homeless or live in poverty, lack the ability to maintain employment or to care for themselves 12. suffer from chronic diseases, have a greater demand for health care services 13. together with the family you develop a caring partnership to recognize actual and potential health care needs and identify community resources 14. assumes responsibility for the case management of multiple clients 15. acts to empower individuals and their families to creatively solve problems or become instrumental in creating change within a health care agency 16. often is the one who presents the client’s point of view to obtain appropriate resources 17. is essential for exploring client issues, knowing the contributions of each profession, clarifying roles, and developing a plan of care 18. assists clients in identifying and clarifying health problems and in choosing appropriate courses of action 19. goal is to help clients assume the skills and knowledge needed to care for themselves



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20. may be involved in case finding, health teaching, and tracking incident rates

21. a.

structure (geographical boundaries, emergency services, housing, economic status)

b.

population (age and sex distribution, growth trends, education level, ethnic and religious groups) c. social (education and communication systems, government, volunteer programs, welfare system) 22. 3. Because nurses provide direct care services where clients live and work, it is important to focus on the individual and family and respect and incorporate the values of the community. 23. 3. They are usually jobless and do not have the advantage of shelter and cope with finding a place to sleep at night and finding food. 24. 4. the coordinating of activities of multiple providers and payers in different settings throughout a client’s continuum of care 25. 3. observe the community’s design, location of services, and locations where the residents meet



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Chapter 4: Theoretical Foundations of Nursing Practice

1. c 2. d 3. e 4. f 5. a 6. b 7. e 8. f 9. a 10. d 11. h 12. i 13. j 14. c 15. g 16. b 17. Piaget’s theory of cognitive development helps to explain how children think, reason, and perceive the world. 18. Neuman defines a total-person model of holism and an open-systems approach. As an open system, a person interacts with the environment. 19. a. physiological needs (air, water, food) b. safety and security needs (physical and psychological) c. love and belonging needs (friends, social relationships, and sexual love) d. esteem and self-esteem needs (self-confidence, usefulness, achievement, and self-worth) e. self-actualization 20. d 21. e 22. g 23. I 24. C 25. B 26. F 27. H 28. A 29. 4. The 4 dimensions (energy fields, openness, pattern and organization, and dimensionality) aid in the development of principles related to h uman development. 30. 4. Nurses needing to know all about the disease process were early attempts to differentiate between nursing and medicine. 31. 3. 32. 2. nursing science, basic social sciences, physical sciences, biobehavioral sciences, ethics, and health policy



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Chapter 5: Evidence-Based Practice

1. is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician’s expertise, client preferences, and values in making decisions about client care 2. a. ask a clinical question. b. collect the most relevant evidence c. clinically appraise the evidence d. integrate all the evidence with one’s clinical expertise, client preferences, and values in making a practice decision e. evaluate the practice decision 3. a. P = patient/population of interest b. I = intervention of interest c. C = comparison of interest d. O = outcome 4. agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, or computerized databases 5. means that a panel of experts familiar with the article’s topic or subject matter has reviewed the article 6. systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific client population 7. Controlled trials without randomization are studies that test interventions, but researchers have not randomized the subjects into the control or treatment groups. 8. summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice 9. contains information about its purpose and the importance of the topic for the reader 10. a detailed background of the level of science or clinical information that exists about the topic of the article 11. A clinical article can contain a description of the population, the health alteration, how clients are affected, or a new therapy or technology. A research article contains a purpose statement, methods, or design. 12. In a clinical article, the author will explain the clinical implications for the topic presented. In a research article, the author will detail the results of the study and explain whether a hypothesis is proven or how a research question is answered. 13. A research article will include a section that explains if the findings from the study have clinical implications. 14. apply the research in your plan of care for a client, use the evidence you find as a rationale for an intervention you plan to try, such as teaching tools, clinical practice guidelines, policies and procedures, new tools. 15. is a way to identify new knowledge, improve professional education and practice, and use resources effectively 16. is research designed to assess and document the effectiveness of health care services and interventions



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17. is a systematic step-by-step process that ensures that the findings from a study are valid, reliable, and generalizable to subjects 18. a. identify the problem area to be studied b. steps of planning occur in an orderly fashion c. control external factors that may influence a relationship between the phenomena that are being studied d. empirical data is gathered e. goal is to understand the phenomena 19. the conditions are tightly controlled to eliminate bias and to ensure that findings can be generalizable to similar subjects 20. obtain information from populations regarding the frequency, distribution, and interrelation of variables among the subjects 21. it involves finding out how well a program, practice, procedure, or policy is working 22. involves inductive reasoning to develop generalizations or theories from specific observations or interviews 23. a. involves the description and interpretation of cultural behavior b. with a focus on what people experience in regard to daily practices or experiences and how they interpret those experiences c. is a method of collecting and analyzing data with the aim of developing theories and propositions that are grounded in the real world 24. a. identify the area of interest or clinical problem b. design the study protocol c. obtain necessary approvals, recruit subjects, and implement the study d. analyze the results of the study e. formulate recommendations for future research 25. an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others 26. The organization evaluates and analyzes current performance to use results to develop focused improvement actions. 27. 3. Together, the abstract and introduction tell you if the topic of the article is similar to your PICO question or related closely enough to provide you with useful information. 28. 3. The summary details the results of the study and explains whether a hypothesis is supported. The results of other studies are not p resented. 29. 4. systemically developed statements about a plan of care for a specific set of clinical circumstances involving a specific client population



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Chapter 6: Health and Wellness

1. Different attitudes about illness cause people to react in different ways to the illness of a family member. 2. a. to increase quality and years of healthy life b. to eliminate health disparities 3. a. promote healthy behaviors b. promote healthy and safe communities c. improve systems for personal and public health d. prevent and reduce disease and disorders 4. a state of complete physical, mental, and social well-being. 5. Positive: activities related to maintaining, attaining, or regaining good health and preventing illness Negative: practices that actually or potentially are harmful to health 6. a. individual’s perception of susceptibility to an illness b. individual’s perception of the seriousness of the illness c. the likelihood that a person will take preventative action 7. a. the individual characteristics and experiences b. behavior-specific knowledge and affect c. behavioral outcomes 8. The clients are the ultimate experts regarding their own health, and one should respect clients’ subjective experience as relevant in maintaining health or assisting in healing 9. a. developmental stage (finding the patterns or general principles that apply to most people most of the time; the concept of illness is dependent on the developmental stage of the individual) b. intellectual background (shaped by the person’s knowledge or lack of knowledge or incorrect information) c. perception of functioning (subjective data about the way clients perceive their physical functioning) d. emotional (the degree of stress, depression, fear) e. spiritual factors (values and beliefs exercised by the patient) 10. a. family practice: the way in which clients’ families use health care services generally affects their health practices b. psychosocial variables: the stability of the person’s marital or intimate relationship, lifestyle habits, and occupational environment c. influences beliefs, values, and customs that will influence their personal health practices, their approach to the system, and the nurse-client relationship 11. Activities such as routine exercise and good nutrition help clients maintain or enhance their present levels of health.



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12. strategies that are designed to help persons achieve new understanding and control over their lives 13. activities that motivate people to avoid declines in health or functional levels 14. a. individuals gain from the activities of others without acting themselves b. individuals are motivated to adopt specific health programs 15. a. is true prevention; it precedes disease b. focuses on the individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions c. occurs when a defect or disability is permanent and irreversible; it involves minimizing the effects of the illness or disability 16. is any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident 17. a. pregnant or overweight, diabetes mellitus, cancer, heart disease, kidney disease or mental illness b. premature infant, heart disease, and cancer with increased age c. industrial workers and the risk of cancer d. habits that have risk factors (sunbathing, overweight) 18. a. not intending to make changes within the next 6 months b. considering a change within the next 6 months c. making small changes in preparation for a change in the next month d. actively engaged in strategies to change behavior e. sustained change over time 19. a state in which a person’s physical, emotional., intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with the previous experience 20. a. usually has a short duration and is severe; symptoms appear abruptly, are intense, and often subside after a relatively short period b. usually lasts longer than 6 months; can also affect functioning in any dimension 21. how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system 22. a. their perceptions of symptoms and the nature of their illness--a person experiencing chest pain in the middle of the night seeking assistance b. the visibility of symptoms, social group, cultural background, economic variables, accessibility of the system, and social support 23. a. depend on the nature of the illness, the client’s attitude toward it, the reaction of others to it, and the variables of the illness behavior


Study Guide Answer Key b.

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reaction to the changes in body image depend on the type of changes, their adaptive capacity, the rate at which changes takes place, and the support services available c. depends in part on body image and roles but also includes other aspects of psychology and spirituality d. role reversal can lead to stress, conflicting responsibilities for the adult or child, or direct conflict over decision making e. is the process by which the family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges 24. 4. Internal variables include all of the ones cited. 25. 1. any situation, habit, or social or environmental condition that increases the vulnerability of the individual to an illness 26. 2. Illness behavior involves how people monitor their bodies, define and interpret their symptoms, take action, and use the health care system. 27. 1. The health belief model helps nurses understand factors influencing clients’ perceptions, beliefs, and behavior.



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Chapter 7: Caring for the Cancer Survivor

1. a. due to cancer treatment, genetic or other susceptibility, or an interaction between treatment and susceptibility b. osteoporosis, congestive heart failure, diabetes, amenorrhea, sterility, impaired immune function, paresthesias, and hearing loss c. treatment for the cancer or the cancer itself can cause pain and neuropathy d. associated sleep disturbances are the most frequent and disturbing complaints e. in systemic cancer treatment, including chemotherapy or biotherapy, there are generalized, subtle effects ranging from small deficits in information processing to acute delirium 2. numbness in the chest wall or axilla, tightness, pulling in the arm or axilla, fatigue, difficulty sleeping, and hot flashes 3. a. range along a continuum from sadness to disabling depression, long-term fatigue, and sleep disturbances leading to depression b. is a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation. Females who are young, less educated, low-income, and less social and who lack emotional support are at high risk for PTSD. c. a client’s body image or altered sexual function 4. a. alters a young person’s social skills, sexual development, body image, and the ability to think about and plan for the future b. every family member’s role, plans, and abilities change; added job responsibilities for the spouse; changes in sexuality, intimacy, and fertility; employment opportunities are affected; economic burdens c. retire prematurely, fixed income, limitations of Medicare reimbursement, retirement residences, isolated from social supports 5. a. energy-consuming anxiety b. inability to forgive c. low self-esteem d. maturational losses e. mental illness 6. Caregivers report a lower quality of life than that of their other family members, find themselves ill-prepared to deal with the diagnosis, struggle with interpersonal problemsolving, and struggle to maintain core functions. 7. Some examples may be: Have you had any pain or discomfort in the area where you had surgery or radiation? Are you experiencing fatigue, sleeplessness, or shortness of breath? How distressed are you feeling at this point on a scale of 0-10? How do you think your family is doing with the cancer? If you have had sexual changes, what strategies have you tried to make things better? 8. Reinforce their health care provider’s explanations of the risks related to their cancer and treatment, what they need to self-monitor, and what to discuss with health care providers in the future.


Study Guide Answer Key 9. a. prevention and detection of new cancers and recurrent cancer b. surveillance for cancer spread, recurrence, or second cancers c. intervention for consequences of cancer and its treatments d. Review survivorship care plan with client at time of discharge. 10. 4. Cognitive changes can occur during all phases of the cancer experience, from small deficits in information processing to acute delirium. 11. 4. Many older adults have very limited Medicare reimbursement. 12. 2. Coordination should be between the specialists and the primary care providers for ongoing clinical care.


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Chapter 8: Caring in Nursing Practice

1. A universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another. 2. the concept of care as the essence and central, unifying, and dominant domain that distinguishes nursing from other health disciplines. Care is the essential human need and is necessary for the health and survival of all individuals. 3. looks beyond the client’s disease and its treatment by conventional means. It looks for deeper sources of inner healing to protect, enhance, and preserve a person’s dignity, humanity, wholeness, and inner harmony. 4. a connection between the one cared for and the one caring. The relationship influences both the nurse and the client, for better or worse. 5. a. striving to understand an event as it has meaning in the life of the other b. being emotionally present to the other c. doing for the other as he or she would do for the self if it were at all possible d. facilitating the other’s passage through life transitions e. sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning 6. the nurse as the client’s advocate, solving ethical dilemmas by attending to relationships and by giving priority to each client’s unique personhood. 7. person-to-person encounter that conveys a closeness and a sense of caring. Presence involves being there and being with. 8. a. when performing a task or a procedure, the skillful and gentle performance of a nursing procedure conveys security and a sense of competence b. a form of nonverbal communication, which successfully influences the client’s comfort and security, enhances self-esteem, and improves reality orientation c. used to protect the nurse and/or client, it can be positive or negatively viewed 9. taking in what a client says, as well as an interpretation and understanding of what the client is saying and giving back that understanding to the person who is speaking. 10. a. mobilizing hope for the client and for the nurse b. finding an interpretation or understanding of illness, symptoms, or emotions that is acceptable c. assisting the client using social, emotional, or spiritual resources d. recognizing that caring relationships connect us in a human-to-human, spiritto-spirit way 11. a. b. c. d. e. f.

being honest advocate for the client’s care preferences giving clear explanations keeping family members informed make the patient comfortable showing interest in answering questions honestly



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g. provide necessary emergency care h. client privacy i. all nursing services will be available j. helping clients to do as much for themselves as possible k. teach the patient how to keep the relative physically comfortable 12. Nurses are torn between the human caring model and the task-oriented biomedical model and the institutional demands that consume their practice. 13. 2. Even though human caring is a universal phenomenon, the expressions, processes, and patterns of caring vary among cultures. 14. 4. There is a mutual give-and-take that develops as nurse and client begin to know and care for one another. 15. 3. Listening involves paying attention to the individual’s words and the tone of his or her voice. 16. 4. depends on the family’s willingness to share information about the client, their acceptance and understanding of therapies, whether the interventions fit the family’s daily practices, and whether the family supports and d elivers the therapies recommended



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Chapter 9: Culture and Ethnicity

1. c 2. e 3. h 4. f 5. d 6. i 7. l 8. m 9. j 10. k 11. b 12. g 13. a 14. a. attribute illness to natural, impersonal, and biological forces that cause alteration in the equilibrium of the human body b. believe that an external agent, which can be human or nonhuman, causes health and illness 15. c 16. e 17. a 18. b 19. d 20. is a systematic and comprehensive examination of the cultural care values, beliefs, and practices of individuals, families, and communities 21. aim is to encourage clients to describe values, beliefs, and practices that are significant to their care that health care providers will take for granted unless otherwise uncovered 22. knowledge of a client’s country of origin and its history and ecological contexts. Similarities shared by an immigrant group with the dominant culture in society are strong predictors of assimilation. 23. Some distinct health risks are due to the ecological context of the culture; certain genetic disorders are also linked with specific ethnic groups. 24. Although different configurations of a family exist, the most common is the nuclear household made up of parents and their young children. Collectivistic groups often regard members of their ethnic groups as closest kin and want to consult them. Social hierarchy and roles are further defined by the culture. 25. Religious and spiritual beliefs are major influences on the client’s views about health, illness, pain and suffering, and life and death. 26. Different cultural groups have distinct linguistic and communication patterns that reflect core cultural values. 27. Differences exist in the dimensions of time that cultures emphasize and also in the manner of expressing time.



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28. Caring expressions integrate the central values and collectivistic active involvement of the group, emphasizing mutual and reciprocal obligations of members. American culture (self-care ideology and individualism). 29. a. respect for and about b. concern for and about c. attention to details d. helping and assisting e. active listening f. presence g. understanding h. connectedness i. protection j. touching k. comfort measures 30. a. retains and/or preserves relevant care values b. adapt or negotiate with others for satisfying health outcomes c. reorder, change, or modify client’s lifestyle 31. 1. Involves racial, ethnic, religious, and social groups 32. 2. Nurses need to determine how much an individual’s life patterns are consistent with his or her heritage. 33. 2. Due to the changing demographic profile of the United States in relation to immigration and significant culturally diverse populations 34. 1. Due to the fact that different cultural groups have distinct linguistic and communication patterns



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Chapter 10: Caring for Families Define the three important attributes that characterize contemporary families 1. Durability : is the intrafamilial system of support and structure that extends beyond the walls of the household 2. Resiliency : the ability of the family to cope with expected and unexpected stressors 3. Diversity : the uniqueness of each family unit; each person has specific needs, strengths, and important developmental considerations 4. A family is defined as : defined biologically, legally, or as a social network with personally constructed ties and ideologies Current Trends and New Family Forms Summarize the various family forms 5. Nuclear family : consists of the husband and the wife (and perhaps one or more children) 6. Extended family : includes relatives in addition to the nuclear family 7. Single-parent family : one parent leaves the nuclear family because of death, divorce, or desertion, or when a single person decides to have or adopt a child 8. Blended family : Parents bring unrelated children from prior or foster-parenting relationships into a new, joint living situation. 9. Alterantive patterns of relationships: multi-adult households, skip-generation families and communal groups with children, nonfamilies, cohabiting partners and homosexual partners Explain the following threats and concerns facing the family 10. Changing economic status : Two-income families have become the norm, but the incomes have not increased. Families at the lower end of the income scale have been particularly affected, and single- parent families are especially vulnerable. 11. Homelessness : absolute: people without physical shelter who sleep outdoors in places that are not intended for human habitation. Relative: those who have physical shelter but one that does not meet the standards of health and safety. 12. Family violence : emotional, physical, and sexual abuse occurs toward spouses, children, and older adults across all social classes. Factors are complex and may include stress, poverty, social isolation, psychopathology, and learned family behavior. 13. Acute and chronic illness : acute: family members are left in waiting rooms to anticipate information about their loved one. Chronic: family patterns and interactions, social activities, work and household schedules; economic resources must be reorganized around the illness or disability. Explain how the following examples impact the family 14. Trauma: Family members need to cope with the challenges of a severe, lifethreatening event that includes many stressors and may impact the family’s functioning and decision-making. 15. Human immunodeficiency virus (HIV): While the epidemic has slowed, high-risk behaviors continue to rise, especially among men who have sex with men.



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16. End of life: The family’s need for information, support, assurance, and presence are great. The more you know about the family, how they interact, and their strengths and their weaknesses, the better. Theoretical Approaches: An Overview Summarize the following general perspectives when working with or studying families 17. Family health system : Interactive, developmental, coping, integrity, and health 18. Developmental stages : Each stage has its own challenges, needs, and resources and includes tasks that need to be completed before the family is able to successfully move on to the next stage. Attributes of Families

19. Structure may enhance or detract from the family’s ability to respond to stressor. Briefly explain each of the following . Rigid Structure: dictates who is able to accomplish a task and may limit the a. number of persons outside the immediate family who assumes these tasks b. Developmental stages : consistent patterns of behavior that lead to a utomatic action do not exist, and enactment of roles is overly flexible 20. Family functioning focuses on the processes used by the family to achieve its goals. Identify these process : communication among family members, goal setting, conflict resolution, caregiving, nurturing, and use of internal and external resources 21. Identify the variables that affect the structure, functions, and health of a family : class and ethnicity (different life chances for its members); distribution of wealth greatly affects the capacity to maintain health; family’s beliefs, values, and practices influence health behaviors.

22. Explain the following attributes of healthy families . hardinesss is the internal strengths and durability of the family unit a. b. resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events Family Nursing Identify the three levels and focuses proposed for family nursing practice. Briefly explain each. 23. Family as context : The primary focus is on the health and development of an individual member existing within a specific environment. 24. Family as client : Family processes and relationships are the primary focus of nursing care. Need to focus on family patterns versus individual characteristics. 25. Family as system: Use both family as context and family as client simultaneously.



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Nursing Process for the Family 26. Three factors underlie the family approach to the nursing process. Name them a. the nurse views all individuals within the family context b. that families have an impact on individuals c. that individuals have an impact on the families 27. Identify areas to include in the family assessment : Interactive, developmental, coping, integrity, and health processes 28. Summarize the challenges for family nursing in relation to each of the following : a. Discharge planning : an accurate assessment of what will be needed for care at the time of discharge, along with any shortcomings in the home setting Cultural diversity : in the family requires recognizing not only the diverse b. ethnic, cultural, and religious backgrounds of clients but also the differences and similarities within the same family 29. When implementing family-centered care, the following need to be addressed. Briefly explain. a. Health promotion : improve or maintain the physical, social emotional and spiritual well-being of the family unit and its members b. Family strengths : clear communication, adaptability, healthy child-rearing practices, support and nurturing among family members, and the use of crisis for growth Acute care: challenges to the family in relation to early discharge and c. employment outside the home. Restorative care : maintain client’s functional abilities within the context of d. the family, as well as find ways to better the lives of the chronically ill and disabled Identify the conflicts that affect the “sandwich generation” 30. Conflicting responsibilities for aging parents, children, spouse, and job. Frequently tries to do it all. May not recognize need for help or may not request help.



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Chapter 11: Developmental Theories 1. Briefly explain the following processes that affect growth and developement a. Biologic processes : produce changes in an individual’s physical growth and development Cognitive processes : comprise changes in intelligence, ability to understand b. and use language, and the development of thinking Socioemotional processes : consist of variations that occur in an individual’s c. personality, emotions, and relationships with others during their lifetime Developmental Theories 2. Briefly summarize Gesell’s theory of development: is that although each child’s pattern if growth is unique, this pattern is directed b y gene activity 3. Explain the five psychosexual developmental stages of Freud’s theroy Stage 1: (oral) sucking and oral satisfaction is not only vital to life, bu t a. pleasurable Stage 2: (anal) children become increasing aware of the pleasurable b. sensations of this body region with interest in the products of their effort c. Stage 3: (phallic) the genital organs become the focus of pleasure d. Stage 4: (latency) sexual urges are repressed and channeled into productive activities that are socially acceptable e. Stage 5: (genital) time of turbulence when earlier sexual urges reawaken and are directed to an individual outside the family circle 4. Trust versus mistrust : Sensorimotor period 5. Autonomy versus shame : Preoperational period 6. Initiative versus guilt : Use of symbols; egocentric 7. Industry versus inferiority : Conrete operations period 8. Identity versus role confusion : Formal operations period

9. Define temperament : is a behavioral style that affects the individual’s emotional interactions with others Gould’s research supports stage theory in adult development with a set of themes. Briefly explain the five themes identified . 10. First Theme: the move away from parental influence is gradual as young adults establish themselves as adults (20s) 11. Second Theme : experience the consequences of the decisions of their independence (early 30s) 12. Third Theme: the impact of a growing family and aging parents influences this time (late 30s) 13. Fourth Theme: resignation and the belief that possibilities are limited (40s) 14. Fifth Theme: a decrease in negativism occurs; a realization of mortality (50s) 15. Contemporary Life-events approach considers : the individual’s personal circumstances, how the person views and adjusts to changes, and the current social and historical context in which the individual is living



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16. Explain the two stages of Piaget’s moral development theroy Heteronomous morality : occurs between 4-7 years and is characterized by a a. belief that rules are unchangeable and that when a rule is broken, there is imminent justice Autonomous morality : child understands that people make rules and that b. they can be changed Kohlberg identified six stages of moral development under three levels. Briefly explain each. 17. Level I: Preconventional level : The person reflects on moral reasoning based on personal gain. Stage 1: Punishment and obedience orientation (in terms of absolute obedience to authority and rules) Stage 2: Instrumental relativist orientation (more then one right view) 18. Level II: Conventional Level : Sees moral reasoning based on his or her own personal internalization of societal and others’ expectations Stage 3: Good boy-nice girl orientation (good motives, showing con cern for others, and keeping mutual relationships) Stage 4: Society-maintaining orientation (expand their focus from a relationship with others to societal concerns) 19. Level III: Post-conventional Level: Balance between human rights and obligations and societal rules and regulations Stage 5: Social contract orientation (follows the societal law but recognizes the possibility of changing the law to improve society) Stage 6: Universal ethical principle orientation (right by the decision of conscience in accord with self-chosen ethical principles)



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Chapter 12: Conception Through Adolescence 1. 2. 3. 4. 5.

Nagele’s rule : Computes the length of preegnancy Fertilization : Sperm penetrates the ovum Germinal period: First 2 weeks after conception Zygote : newly formed organism with its full genetic complement Embryonic period : The beginning of the third week through the eighth week after conception 6. Fetal period: ninth week after conception; ends with birth 7. Teratogens : Factors that are capable of producing functional or structural damage to the fetus 8. Prematurity : infant between 20 to 37 weeks gestation 9. Neonatal period: first month of life 10. Molding: Overlapping of the soft skull bones 11. Fontanels : diamonds and triangular shapes between the unfused bones of the skull 12. Cognitive development : Innate behavior, reflexes, and sensory functions 13. Hyperbilirubinemia : Excessive amount of bilirubin in the blood 14. Inborn errors of metabolism : Genetic disorders caused by the absence of deficiency of a substance essential to cellular metabolism 15. Circumcision : benefits include prevention of penile cancer and urinary tract infectiosn (UTIs) 16. Safety concerns: Car seats and cribs The Infant 17. the period from 1 month to 1 year of age 18. Summarize the physical changes that occur in the infant : size increases rapidly during the first year of life; birth weight doubles (5 months) and triples (12 months). Height increases an average of 1 inch every 6 months until 12 months. 19. Describe the cognitive changes that occur in the infant: learns by experiencing and manipulating the environment; sensorimotor period 20. Identify the language development in the infant and how to help parents further develop the infant’s language : by 1 year, they not only recognize their own names but are able to say three to five words and understand 100 words. The nurse can promote language development by encouraging parents to name objects on which the infant is focusing. 21. Explain the following psychosocial changes that occur a. Separation and individuation : infants are unaware of the boundaries of self, but they learn where the self ends and the external world begins Play: much of the play is exploratory as they use their senses to observe and b. examine their own bodies and objects of interest in their surroundings 22. Explain the following in relation to health risks of the infant Injury Prevention : MVA, aspiration, falls, or poisoning are major causes of a. death b. Child maltreatment : intentional physical abuse or neglect, emotional abuse or neglect, and sexual abuse 23. Briefly explain health concerns related to the following



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a.

Nutrition: feeding alternatives: breast feeding is recommended; the use of whole cow’s milk is not recommended before 12 months Immunization: recommended that the administration of the primary series b. begin after birth and be completed during early childhood Sleep: infants are nocturnal and sleep between 9 and 11 hours, averaging 15 c. hours a day The Toddler 24. Toddlerhood ranges from 12-36 months 25. Describe language ability at this stage : 10 words to 300 words and is able to speak in two-word sentences. 26. Describe the moral development of a toddler : they do not understand the concepts of right and wrong; they do grasp pleasant and unpleasant results 27. Identify the health risks of a toddler : locomotion abilities and curiosity; poisoning occurs frequently; drowning, MVA The preschooler 28. The preschool period ranges from years between 3 and 5 29. Describe the cognitive changes that occur with the preschooler demonstrate their ability to think in a more complex manner by classifying objects, increased social interaction, cause-and-effect relationships; the world remains closely linked to concrete experiences; their greatest fear is bodily harm 30. Explain the following a. Moral development : begins to understand behaviors that are considered socially right or wrong Language : increases rapidly, is more social, and asks questions for b. information 31. Describe the concept of play for the preschooler engage in similar if not identical activity; there is no division of labor or rigid organization or rules 32. Explain health concerns related to the following for this group a. Nutrition : the quality of food is more important than the quantity Sleep: average 12 hours a night, infrequent naps b. c. Vision: regular intervals of screening The School-Age Child 33. The school-age year range from 6 years until 12 years (puberty) 34. Define the cognitive skills that develop in the school-age child : Define the cognitive skills that develop in the school-age child the ability to think in a logical manner about the here and now and to understand the relationship between things and ideas. They have the ability to concentrate on more than one aspect of a situation and are able to reason about the relationships between classes. 35. Summarize psychosocial development in relation to the following a. Moral – need for moral code and social rules becomes more evident b. Peers – become more important; play involves peers and the pursuit of group goals Sexual – latency period c.


Study Guide Answer Key d.

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Stress – from parental expectations, peer expectations, school environment, violence in the community 36. Identify the health risks for the school-age child : MVA, drowning, burns, substance abuse and poisoning, bodily damage, stranger safety 37. a. food guide pyramid b. mechanics of dental hygiene, biannual check-ups c. immunization information and prevention practices d. prevention programs e. discuss with parents the learning needs of their child; provide age- appropriate education 38. 13-20 years 39. a. Increased growth rate of skeleton, muscle and viscera b. Sex-specific changes c. Alteration in distribution of muscle and fat d. Development of the reproductive system 40. the onset of menstruation 41. ability to determine possibilities, rank and solve problems, and make decisions through logical operations. They can think abstractly and deal effectively with hypothetical problems. They can move beyond the physical or concrete properties of a situation and use reasoning powers to understand the abstract. 42. Do not avoid discussing sensitive issues. Ask open-ended questions. Look for meaning behind the words or actions. Be alert to clues to their emotional state. Involve other individuals and resources. 43. a. puberty enhances sexual identity; physical evidence of maturity encourages the development of behaviors b. similarity in dress or speech and popularity are major concerns c. movement toward stronger peer relationships is contrasted with adolescents' movement from parents d. provides a goal; need to select action that promotes self-satisfaction, identity, and continued opportunity for growth e. depends heavily on cognitive and communication skills and peer interaction. Regarding rules, they learn to use their own judgment rather than use the rules to avoid punishment as in earlier years. f. evaluate their own health according to feelings of well-being, ability to function normally, and absence of symptoms 44. a. accidents b. homicide c. suicide 45. a. decrease in school performance b. withdrawal c. loss of initiative


Study Guide Answer Key d. e. f. 46. a.

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loneliness, sadness, and crying appetite and sleep disturbances verbalization of suicidal thought

physical and psychosocial components that involve the pursuit of thinness through starvation b. binge eating and behaviors to prevent weight gain (vomiting, laxatives, exercise) 47. a. driver’s education and wear seat belts b. screen for use and inform of the risks for use c. education about STDs; encourage abstinence d. teach conflict resolution 48. limited access to health care, limited health care insurance, lack of transportation to health care, poverty, and farming accidents 49. learning or emotional difficulties, death related to violence, unintentional injuries, increased rate of adolescent pregnancy, poverty, and limited access 50. 4. toddlers often develop food jags or the desire to eat one food repeatedly; continue to offer a variety of nutritious foods 51. 1. do not understand what is right or wrong, but they do understand positive and negative reinforcement, thus learning self control 52. 1. The school and home influence growth and development. If they are positively recognized for success, they feel a sense of worth. 53. 4. They establish close relationships and make choices about their vocation; morality comes from individual principles of conscience.



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Chapter 13: Young to Middle Adult

1. the period between the late teens and the mid to late 30s 2. general life satisfaction, hobbies and interests, habits, home conditions and pets, economics, occupational environment, physical and mental strain 3. formal and informal educational experiences, general life experiences, and occupational opportunities increase conceptual problem-solving and motor skills 4. a. the person refines self-perception and ability for intimacy b. the person directs enormous energy toward achievement and mastery of the world c. time of vigorous examination of life goals and relationships 5. a. identification of modifiable factors that increase the risk for health problems and provide education and support b. the two-career family has benefits and liabilities with resulting stressors c. psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse d. conception, pregnancy, birth, and the puerperium are the major phases 6. a. many do not marry until late 20s or early 30s; remain single; expanding careers for women; and divorce b. availability of contraception, economic considerations, general health status and age c. cohabitation without marriage; gay and lesbian 7. the presence of certain chronic illnesses in the family increases the patient’s risk of developing a disease, distinct frrm hereditary disease 8. sharing utensils, poor dental hygiene 9. due to poverty, family breakdown, child abuse and neglect, repeated exposure to violence, and access to guns 10. intoxicated MVAs, stimulants, excessive caffeine use 11. exploration of situational factors that affect the progress and outcome (financial, career, living accommodations, family support systems, parenting disorders, depression, and coping mechanisms) 12. major health problem and leads to chronic disorders, infertility, or death 13. exposure to work-related hazards or agents, which can cause disease and cancer 14. a prolonged time to conceive, comprehensive histories of both the female and male partners to determine factors that affect fertility as well as pertinent physical findings 15. important to prevent or decrease the development of chronic health conditions that develop later in life 16. need to perform monthly skin, breast, or male self examinations 17. job stress (situational), family stress (multiplicity of changing relationships and structures), pregnant woman and childbearing 18. prenatal care is the routine thorough physical examination of the pregnant woman 19. irregular, short contractions 20. is the period of approximately 6 weeks after delivery



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21. breast feeding 22. early to mid 30s and last through the late 60s 23. most visible changes are graying of the hair, wrinkling of the skin, thickening of the waist, and decreases in hearing and visual acuity, which may have a impact on selfconcept and body image 24. a. is the period during which ovulation declines, resulting in a diminished number of ova and irregular menstrual cycles b. is the disruption of this cycle, primarily because of the inability if the neurohormonal system to maintain its periodic stimulation of the endocrine system. c. occurs in men in their late 40s or early 50s due to decreased levels of androgens 25. middle adults having the responsibility of raising their own children while caring for aging parents 26. changes occur by choice or as a result of changes in the workplace or society (limited upward mobility, decreasing availability of jobs, need for challenge) 27. couples recultivate their relationships, menopausal symptoms, stresses due to sexual changes or conflicts 28. choice and freedom; delayed marriage and delayed parenthood, adoption 29. death of a spouse, separation, divorce, and the choice of remarrying or remaining single 30. departure of the last child is a stressor, leading to a readjustment phase 31. goals of wellness and guides clients to evaluate health behaviors, lifestyle, and environment by minimizing the frequency of stress-producing situations, increasing stress resistance, and avoiding physiological response to stress 32. evaluate health behaviors and lifestyle; counseling related to physical activity and nutrition 33. a. related to change, conflict, and perceived control of environment, which may motivate the adult to rethink life goals and stimulates creativity or precipitates psychosomatic illness and preoccupation with death b. risk factors: female, disappointments or losses at work, school or relationships, departure of the last child, and family history 34. 1. factors that predispose include poverty, family breakdown, child abuse and neglect, repeated exposure to violence, and access to guns 35. 3. the most visible changes are the graying of hair, wrinkling of the skin, and thickening of the waist 36. 1. inability of the neurohormonal system to maintain its periodic stimulation of the endocrine system



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Chapter 14: Older Adult

1. 2. 3. 4. 5. 6. a. b. c. d. 7. 8.

age 65 and over d c a b ill, disabled, and physically unattractive forgetful, confused, rigid, bored and unfriendly mistaken ideas about living arrangements undervaluing due to unattractiveness as the result of random cellular damage that occurs over time genetically programmed physiological mechanisms within the body control the process of aging

9. a.

the oldest; states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities b. continuation of activities performed during middle age as necessary for aging c. that personality remains the same and behavior becomes more predictable as people age 10. a. adjusting to decreasing health and physical strength b. adjusting to retirement and reduced or fixed outcome c. adjusting to the death of a spouse d. accepting self as aging person e. maintaining satisfactory living arrangements f. redefining relationships with adult children g. finding ways to maintain quality of life 11. a. home (should not feel like a hospital) b. care (staff actively assisting and interacting socially) c. family involvement (should encourage involvement) d. environment (ample lighting, minimal noise, plants, pets) e. communication (respectful and considerate) f. staff (attentive to resident requests) 12. the interrelation between physical and psychosocial aspects of aging 13. the effects of disease and disability on functional status 14. the decreased efficiency of homeostatic mechanisms 15. the lack of standards for health and illness norms 16. altered presentation and response to specific disease 17. a. change in mental status b. falls c. dehydration d. decrease in appetite



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e. loss of function f. dizziness and incontinence 18. d 19. f 20. g 21. b 22. i 23. j 24. h 25. e 26. a 27. c 28. Functional status refers to the capacity and safe performance of activities of daily living (ADLs) and is a sensitive indicator of health and illness. 29. a. acute confusional state; potentially reversible; often due to a physiological cause b. generalized impairment of intellectual functioning that interferes with social and occupational functioning c. not a normal part of aging 30. a. stage of life characterized by transitions and role changes (health status, option to continue working, sufficient income) b. by choice (desire not to interact with others) or a response to conditions that inhibit the ability or the opportunity to interact with others c. whether healthy or frail there is a need to express sexual feelings (love, warmth, sharing and touching) d. the ability to live independently strongly determines housing choices (social roles, family responsibilities, health status) e. death of a spouse affects more older women then men 31. a. heart disease b. cancer c. CVA d. lung disease e. accidents/falls f. diabetes g. kidney disease h. liver disease 32. a. participation in screening activities b. regular exercise c. weight reduction. d. eating a low fat, well-balanced diet e. regular dental visits f. smoking cessation



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g. immunizations 33. c 34. h 35. e 36. g 37. k 38. i 39. l 40. m 41. a 42. f 43. b 44. d 45. j 46. c 47. e 48. d 49. b 50. f 51. a 52. causes include delirium, untreated UTIs, excessive urine production, medications, depression, restricted mobility, and constipation 53. related to changes in aging and to immobility, incontinence, and malnutrition 54. intrinsic (gait and balance problems, weakness, or cognitive impairment) or extrinsic (polypharmacy, poor lighting, cluttered environment) 55. a. continues the recovery from acute illness or surgery that began in the acute care setting b. addresses chronic conditions that affect day-to-day functioning 56. 4. It potentially is a reversible cognitive impairment that is often due to physiological causes. 57. 3. Beyond caloric requirements, therapeutic diets restrict fat, sodium, or simple sugars or increase fiber or foods high in ca lcium, iron, and vitamins A or C. 58. 1. Often due to the result of retinal damage, reduced pupil size, development of opacities in the lens or loss of lens elasticity 59. 4. It is the stage of life characterized by transitions and role changes.


Study Guide Answer Key Chapter 15: Critical Thinking in Nursing Practice

1. Is an active, organized, cognitive process used to examine one’s thinking and the thinking of others. 2. based on research or clinical expertise 3. a. seek the true meaning of a situation b. be tolerant of different views and own prejudices c. anticipate possible results or consequences d. be organized e. trust in your own reasoning processes f. be eager to acquire new knowledge and value learning g. reflect upon your own judgments 4. a. trust that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles b. begin to separate themselves from authorities, analyze and examine choices more independently c. anticipate the need to make choices without assistance from others, accountability 5. c 6. d 7. a 8. g 9. b 10. f 11. e 12. a. knowledge base b. experience c. critical-thinking competencies d. attitudes e. standards 13. c 14. g 15. j 16. a 17. e 18. h 19. d 20. f 21. b 22. i 23. k 24. a. is a guideline or principle for rational thought


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refers to ethical criteria for nursing judgments; evidence-based used for evaluation and criteria for professional responsibility 25. is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning 26. is a visual representation of client problems and interventions that shows their relationships to one another 27. 4. involves recognizing an issue exists, analyzing information, evaluating information, and making conclusions 28. 4. the 5 steps are assessment, diagnosis, plan, interventions, evaluation 29. 3. identifying a client’s health care needs 30. 4. implementation


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Chapter 16: Nursing Assessment

1. d 2. e 3. b 4. c 5. a 6. health perception-health management pattern 7. nutritional-metabolic pattern 8. elimination pattern 9. activity-exercise pattern 10. sleep-rest pattern 11. cognitive-perceptual pattern 12. self-perception-self-concept pattern 13. role-relationship pattern 14. sexuality-reproductive pattern 15. coping-stress tolerance pattern 16. value-belief pattern 17. a. subjective – clients’ verbal descriptions of their health problems b. objective – observations or measurements of a client’s health status 18. a. client b. family and significant others c. health care team d. medical records e. literature 19. a. introduce yourself, explain your role b. establish a caring therapeutic relationship c. get insight about the client’s concerns d. determine the client’s goals and expectations e. obtain cues about which parts of the data collection phase require further investigation 20. a. an individual’s past, present, or future physical or mental health or condition b. the provision of health care to the individual c. the past, present, or future payment for provision of health care to the individual 21. data about the client’s current level of wellness, review of systems, family history, sociocultural history, spiritual history, and mental and emotional reactions to illness 22. a. open ended: prompts clients to describe a situation in more than one or two words b. back-channeling: active listening prompts c. closed-ended: limit the client’s answers to one or two words


Study Guide Answer Key 23. f 24. g 25. e 26. h 27. i 28. c 29. j 30. b 31. a 32. d 33. is the comparison of data with another source to determine data accuracy 34. involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a conclusion about the client’s responses to a health problem 35. timely, thorough, and accurate; record all observations; pay attention to facts and be descriptive; record objective information in accurate terminology; do not generalize or form judgments 36. 4. Prompts clients to describe a situation in more than one or two words 37. 1. Some may be focused, and others may be comprehensive. 38. 3. Takes information provided in the client’s story and then more fully describes and identifies specific problem areas 39. 2. asking questions about the normal functioning of each system and the changes are usually subjective data perceived by the client


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Chapter 17: Nursing Diagnosis

1. 2. 3. 4. 5. 6. 7. 8.

d e f b c g a is the name of the diagnosis as approved by NANDA; it describes the essence of the client’s response to health conditions 9. is a condition or etiology identified from the client’s assessment data, actual or potential responses to the health problem 10. the cause of the nursing diagnosis within the domain of nursing practice 11. describes the characteristics of the human response identified 12. are environmental, physiological, psychological, genetic, or chemical 13. is the one way to graphically represent the connections between concepts and ideas that are related to a central subject 14. Review your level of comfort and competence with interview and physical assessment skills. 15. Approach assessment in steps. 16. Review your clinical assessment skills. 17. Determine the accuracy of your data. 18. Be organized in any examination. 19. Review your data base to decide if it is accurate and complete; be careful to consider any conflicting cues or if there is insufficient cues to co nfirm a diagnosis. 20. Avoid premature clustering of data; always identify the nursing diagnosis from the data, not the reverse. 21. Word the diagnostic statement in appropriate, concise, and precise language; use correct terminology; identify the client problem rather than the goal; make professional rather than prejudicial judgments; avoid legally inadvisable statements. 22. 4. Provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is responsible. 23. 4. is the diagnostic label that describes the essence of a client’s response to health conditions 24. 4. It is associated with the client’s actual or potential response to the health problem. 25. 2. the client’s actual or potential response to the health problem



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Chapter 18: Planning Nursing Care

1. a. b. c. 2. 3. 4. 5. 6. 7. 8.

if untreated, result in harm to the client or others involve nonemergent, non-threatening needs of the client are not always directly related to a specific illness or prognosis

d b e c f a outcomes and goals reflect the client’s behavior and responses expected as a result of nursing interventions 9. precise in evaluating a client response to a nursing action; addresses only one behavior or response per goal 10. be able to observe if a change takes place in a client’s status 11. terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely 12. indicates when you expect the response to occur 13. ensure that the client and nurse agree on the direction and time limits of care 14. that a client is able to reach 15. nurse-initiated interventions that do not require direction or an order from another health care professional 16. physician-initiated interventions that require an order for a physician or other health care professional 17. interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals 18. a. characteristics of the nursing diagnosis b. goals and expected outcomes c. evidence-based interventions d. feasibility of the interventions e. acceptability to the client f. your own competency 19. direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care; identifies and coordinates resources for delivering care; lists the interventions needed to achieve the goals of care 20. useful for learning the problem-solving technique, nursing process, skills of written communication, and organizational skills needed for nursing care 21. are part of the client’s legal record and differ by setting and the evolving client situation 22. format is standardized plans, which the nurses are able to individualize for a specific client 23. multidisciplinary treatment plans that outline treatments or interventions clients need to have; most are based on medical diagnoses rather then nursing



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24. Gather the clinical assessment data base from the client’s medical record. 25. Review all of the information about the client’s problems, treatments, and medication in the literature. 26. Review any standardized care plans, critical pathways, protocols, or client education material. 27. First, develop a skeleton diagram of the client’s chief medical diagnosis and patterns of assessment data. Identify and group the related patterns. 28. Review your assessment patterns and identify nursing diagnoses. 29. When planning, analyze relationships among the nursing diagnoses. 30. List the nursing interventions to attain the outcomes for each nursing diagnosis. 31. Use the map to write down the responses to each nursing activity. 32. Revise, take notes, and add or delete nursing interventions. 33. is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies 34. a. identify the general problem area b. direct the consultation to the right professional c. provide the consultant with relevant information about the problem area d. do not prejudice or influence the consultants e. be available to discuss the findings and recommendations f. incorporate the recommendations into the plan of care 35. 2. is an objective behavior or response that you expect a client to achieve in a short time, usually less than a week 36. 4. is the measurable change in a client’s condition that you expect to occur in response to the nursing care 37. 3. The nurse sets client-centered goals and expected outcomes and plans nursing interventions.



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Chapter 19: Implementing Nursing Care

1. a.

is any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes b. are treatments performed through interactions with clients c. are treatments performed away from the client but on behalf of the client 2. a. review the set of all possible interventions for the client’s problem b. review all of the possible consequences associated with each possible nursing action c. determine the probability of all possible consequences d. make a judgment of the value of that consequence to the client 3. or protocol is a document that guides decisions and interventions for specific health care problems or conditions. 4. is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for clients with identified clinical problems 5. offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes 6. continuous process that occurs each time you interact with a client; you collect new data, identify a new client need, and modify the care plan 7. If the client’s status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. 8. organization of equipment, skilled personnel, and the environment 9. Risks to patients come from both the illness and the treatments. 10. includes cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities) 11. activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, grooming) 12. skills such as shopping, preparing meals, writing checks, taking medications 13. involve the safe and competent administration of nursing procedures 14. is a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships 15. the focus of change is intellectual growth or the acquisition of new knowledge or psychomotor skills 16. is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention 17. promote health and prevent illness to avoid the need for acute or rehabilitative health care 18. represents the contributions of all disciplines caring for the client 19. noninvasive and frequently repetitive interventions can be assigned to assistive personnel (nurse assistant). The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care.



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20. that clients and families invest time in carrying out required treatments to achieve client goals 21. 4. the nurse needs to exercise good judgment and decision-making before actually delivering any interventions 22. 2. certain nursing situations require you to obtain assistance by seeking additional personnel, knowledge, and/or nursing skills. You will need assistance with this patient to help turn and position the client safely. 23. 1. guides decisions and interventions for specific health care problems or conditions 24. 1. an acquisition of new knowledge or psychomotor skills



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Chapter 20: Evaluation

1. to determine if you met the expected outcomes, not if the nursing interventions were completed. They are the standards against which the nurse judges if goals have been met and if care is successful. 2. a. identifying evaluative criteria and standards b. collecting data to determine whether the criteria or standards are met c. interpreting and summarizing findings d. documenting findings and any clinical judgment e. terminating, continuing, or revising the care plan 3. a. examine the outcome criteria to identify the exact desired client behavior b. assess the client’s actual behavior or response c. compare the established outcome criteria with the actual behavior d. judge the degree of agreement between outcome criteria and the actual behavior e. if there is no agreement between the outcome criteria and the actual behavior, what are the barriers? 4. Determine if your goals have been met, and then adjust the plan of care accordingly. 5. If the nurse and the patient agree that the expected outcomes and goals have been met, then discontinue that portion of the care plan. 6. Identify the factors that interfere with goal achievement or an error in nursing judgment or failure to follow each step of the nursing process. 7. Determine if the goals were appropriate, realistic, and time-appropriate 8. the appropriateness of the interventions selected and the correct application of the intervention 9. an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others 10. managing the individual clinical outcomes of clients as a result of prescribed treatments 11. 2. Determines whether the client’s condition or well-being has improved after the application of the nursing process 12. 2. Whenever you have contact with a client, you continually make clinical decisions and redirect nursing care; this is an ongoing process 13. 2. They are the expected favorable and measurable results of nursing care. 14. 3. If the goals have not been met, you may need to adjust the plan of care by the use of interventions, modify or add nursing diagnoses with appropriate goals and expected outcomes, and redefine priorities.



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Chapter 21: Managing Client Care

1. d 2. e 3. b 4. a 5. j 6. c 7. f 8. h 9. i 10. g 11. establishment of nursing practice or problem-solving committees or professional shared governance councils 12. nurse/physician collaborative practice 13. interdisciplinary collaboration 14. staff communication 15. staff education 16. The first activity involves a focused and complete assessment of the client’s condition to allow for an accurate clinical decisions as to the client’s health problems and required nursing therapies. 17. need to set priorities: high (immediate threat), intermediate (non-emergent, non-lifethreatening), low (actual or potential problems) 18. effective use of time doing the right things 19. Administration of client care occurs more smoothly when staff members work together. 20. goal setting, time analysis, priority setting, interruption control, evaluation 21. is an ongoing process that compares actual client outcomes with expected outcomes 22. A professional environment is one in which staff members respect one another’s ideas, share information, and keep one another informed. 23. a. right task b. right circumstances c. right person d. right direction/communication e. right supervision 24. a. assess the knowledge and skills of the delegate b. match tasks to the delegate’s skills c. communicate clearly d. listen attentively e. provide feedback 25. 4. As a student nurse, you have a responsibility for the care given to your clients, and you assume accountability for that care.



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Chapter 22: Ethics and Values

1. 2. 3. 4. 5. 6. a. b. c. d. 7.

d b e c a

responsibility accountability confidentiality advocacy personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior 8. development of values begins in childhood; shaped by experiences within the family unit with individual experiences influencing further value formation 9. need to distinguish between value, facts, and opinion 10. a system of ethics that defines actions as right or wrong based on their “right-making characteristics such as fidelity to promises, truthfulness, and justice”; does not look at the consequences of actions 11. value of something is determined by its usefulness; the main emphasis is on the outcome or consequence of actions 12. focuses on inequalities between people; it looks to the nature of relationships for guidance 13. focuses on understanding relationships, especially personal narratives 14. You are able to resolve it solely through a review of scientific data. 15. It is perplexing. 16. The answer to the problem will have a profound relevance for areas of human concern. 17. a. ask the question b. gather information relevant to the case c. clarify values d. verbalize the problem e. identify possible causes of action f. negotiate a plan g. evaluate the plan over time 18. education, policy recommendation, and case consultation 19. helps a client and family decide on the merits of certain risky interventions 20. conditions that are not yet evident but that are certain to develop in the future 21. interventions unlikely to produce benefit for the client 22. 2. Ethical problems come from controversy and conflict. 23. 4. The ethics committee is an additional resource for clients and health care professionals.



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24. 4. Incorporate as much information as possible from a variety of sources such as lab and test results, clinical state of the client, current literature about the condition, and the client’s religious, cultural, and family situation.



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Chapter 23: Legal Implications in Nursing Practice

1. 2. 3. 4. 5. 6. 7. 8. 9.

e h f b c g d a It protects the rights of disabled people. It also is the most extensive law on how employers must treat health care workers and clients infected with HIV. 10. that when a client comes to the ER/hospital, an appropriate medical screening occurs within the hospital’s capacity. If an emergency exists, the hospital is not to discharge or transfer the client until the condition stabilizes. 11. forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits 12. requires health care institutions to provide written information to clients concerning their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives 13. written documents that direct treatment in accordance with a client’s wishes in the event of a terminal illness or condition 14. legal document that designates a person or persons of one’s choosing to make health care decisions when the client is no longer able to make decisions on his or her own behalf 15. An individual over the age of 18 has the right to make an organ donation; needs to make the gift in writing with his or her signature. 16. provides rights to clients (protects individuals from losing their health insurance when changing jobs by providing portability) and protects employees. It also establishes the basis for privacy and confidentiality. 17. a. only to ensure the physical safety of the resident or other residents b. when less restrictive interventions are not successful c. only on the written order of a physician, which includes a specific episode with start and end times 18. The Board of Nursing licenses all RNs in the state in which they practice and can suspend or revoke a license if a nurse’s conduct violates provisions in the licensing statute based on administrative law rules that implement and enforce the statute. 19. law that encourages health care professionals to assist in emergencies, limits liability, and offers legal immunity for nurses who help at the scene of an accident 20. protection of the public’s health, advocating for the rights of people, regulating health care and health care financing, and ensuring professional accountability for the care provided 21. Determination of death requires irreversible cessation of circulatory and respiratory functions or that there is irreversible cessation of all functions of the entire brain, including the brain stem.



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22. Statute that stated that a competent individual with a terminal disease could make an oral and written request for medication to end his or her life in a humane and dignified manner. 23. d 24. g 25. e 26. h 27. i 28. c 29. f 30. j 31. b 32. a 33. Inform their supervisor; they need to make a written protest to nursing administrators. Keep a copy of this document in your own personal file. 34. need to inform the supervisor of any lack of experience in caring for the type of clients on said unit. They also need to request an orientation to the unit. 35. Nurses must follow the physician’s orders unless they believe the orders are in error or will harm the clients. If there is any controversy with the order, the nurse needs to also inform the supervising nurse or follow the established chain of command. 36. system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs 37. provides a database for further investigation in an attempt to determine deviations from standards of care; corrective measures needed to prevent recurrence and to alert risk management to a potential claim situation 38. 1. Determines the legal boundaries within each state 39. 3. Need to perform only those tasks that appear in the job description for a nurse’s aide or assistant 40. 4. conduct that falls below the standards of care 41. 1. unintentional touching without consent 42. 4. need to follow the institution’s policies and procedures on how to handle these situations and utilize the chain of command



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Chapter 24: Communication

1. is a lifelong learning process that is an essential attribute of professional nursing practice 2. a. through the 5 senses b. individual’s culture and education 3. c 4. d 5. b 6. e 7. a 8. g 9. c 10. f 11. j 12. l 13. m 14. a 15. h 16. b 17. i 18. k 19. n 20. e 21. d 22. a. intimate zone (0 –18 inches) b. personal zone (18 in.– 4 ft) c. social zone (9 – 12 ft) d. public zone (12 ft and greater) 23. a. social zone (permission not needed) b. consent zone (special care needed) c. intimate zone (great sensitivity needed) d. vulnerable zone 24. before meeting the client (review data, talk to caregivers, anticipate health concerns, plan enough time for interaction) 25. when the nurse and client meet and get to know one another (set the tone for the relationship, expect to be tested and closely observed, clarify the roles of the client and the nurse) 26. when the nurse and the client work together to solve problems and accomplish goals (help the client to express feelings; self-exploration, set goals, take ac tion, selfdisclosure, and confrontation used appropriately) 27. during the ending of the relationship (termination is near, goal achievement, relinquishing responsibility, transition to other caregivers as needed)



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28. includes the understanding of the complexities of family dynamics, needs, and relationships 29. focuses on team-building, facilitating group processes, collaboration, consultation, delegation, supervision, leadership, and management 30. through channels such as neighborhood newsletters, public bulletin boards, newspapers, radio, TV, and electronic sites to discuss issues important to community health 31. a. courtesy b. use of names c. trustworthiness d. autonomy and responsibility e. assertiveness 32. a. psychophysiological (the internal factors influencing communication) b. relational (the nature of the relationship between the participants) c. situational (the reason for the communication) d. environmental (physical surroundings in which the communication takes place) e. cultural (sociocultural elements that affect the interaction) 33. a. tend to use less verbal communication but are more likely to initiate communication and address issues more directly b. disclose more personal information and use more active listening 34. impaired verbal communication (state in which the individual experiences a decreased, delayed, or absent ability to receive, process, transmit, and use symbols) 35. inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty in comprehending 36. physiological, mechanical, anatomical, psychological, cultural, or developmental 37. a. client initiates conversation about the diagnosis b. client is able to attend to appropriate stimuli c. client conveys clear and understandable messages with team d. client will express increased satisfaction with the process 38. e 39. g 40. m 41. o 42. f 43. a 44. p 45. n 46. l 47. k 48. b 49. j



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50. i 51. c 52. d 53. h 54. g 55. k 56. j 57. f 58. h 59. c 60. e 61. d 62. a 63. i 64. b 65. Listen attentively, do not interrupt, ask simple questions, allow time, use visual cues, do not shout, use communication aids. 66. Reduce distractions, get client’s attention prior to speaking, use simple sentences, ask one question at a time, allow time. 67. Check for hearing aids, reduce noise, get client’s attention, face client, don’t chew gum, speak in a normal voice, rephrase, provide sign language. 68. Check for glasses, identify yourself, speak in normal tone, do not rely on gestures or nonverbal communication, use indirect lighting, use14-font print. 69. Call client by name, verbally and by touch; speak to client as though he can hear; explain all procedures; provide orientation. 70. Speak to client in normal tone, establish method to signal desire to communicate, provide an interpreter, avoid using family, develop communication aids. 71. Determine whether he encourages openness and allow the client to “tell his story” expressing both thoughts and feelings. 72. Identify any missed verbal or nonverbal cues or conversational themes. 73. Examine whether nursing responses blocked or facilitated the client’s efforts to communicate. 74. Determine whether nursing responses were positive and supportive or superficial and judgmental. 75. Examine the type and number of questions asked. 76. Determine the type and number of therapeutic communication techniques used. 77. Discover any missed opportunities to use humor, silence, or touch. 78. 4. means of conveying and receiving messages through visual, auditory, and tactile senses 79. 1. awareness of the tone of verbal response and the nonverbal behavior results in further exploration 80. 3. meaning of a word’s meaning influenced by the thoughts, feelings, or ideas people have about the word 81. 3. motivates one person to communicate with the other 82. 4. personal zone when taking a client’s history



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Chapter 25: Client Education

1. The nurse is a visible, competent resource (information and skills) for clients who want to improve their physical and psychological we ll-being. 2. The nurse learns to identify client’s willingness to learn and motivate interest in learning 3. New knowledge and skills are often necessary for clients to continue ADLs and learn to cope with permanent health alterations. 4. c 5. h 6. f 7. i 8. g 9. e 10. a 11. d 12. b 13. a. denial or disbelief b. anger c. bargaining d. resolution e. acceptance 14. depends on the child’s maturation; intellectual growth moves from the concrete to the abstract as the child matures. Information presented to children needs to be understandable and based on the child’s developmental stage. 15. Adults tend to be self-directed learners; they often become dependent in new learning situations. The amount of information provided and the amount of time varies depending on the client’s personal situation and readiness to learn. 16. To learn psychomotor skills, the following physical characteristics are necessary: size, strength, coordination, and sensory acuity. 17. a. requires assessment of all sources to date to determine a client’s total health care needs b. focuses on the client’s learning needs and willingness and capability to learn 18. a. information or skills needed by the client to perform self-care and to understand the implications of a health problem b. client’s experiences that influence the need to learn c. information that the family members require 19. a. behavior b. health beliefs and sociocultural background c. perception of severity and susceptibility of a health problem and the benefits and barriers to treatment d. perceived ability to perform behaviors


Study Guide Answer Key e. f. g. 20. a. b. c. d. e. f. 21. a. b. c. 22. a. b.

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desire to learn attitudes about providers learning style preference physical strength, movement, dexterity, and coordination sensory deficits reading level developmental level cognitive function physical symptoms that interfere distractions or persistent noise comfort of the room room facilities and available equipment

willingness to have family members and others involved in the teaching plan family members’ perceptions and understanding of the illness and its implications c. willingness and ability to participate in care d. financial or material resources e. teaching tools 23. the inability to read above a fifth-grade level 24. The diagnostic statement describes the specific type of learning need and its cause; classifying the nursing diagnoses by the 3 learning domains helps the nurse focus specifically on subject matter and teaching methods. 25. Base the priorities on the client’s immediate needs (perception of what is most important, anxiety level, and amount of time available), nursing diagnoses, and the goals and outcomes established for the client. 26. Plan for when a client is most attentive, receptive, and alert, and organize the activities to provide time for rest and teaching learning interactions. 27. Organize information into a logical sequence progressing from simple to complex ideas. 28. c 29. e 30. i 31. j 32. h 33. a 34. g 35. d 36. f 37. b 38. legally responsible for providing accurate, timely client information that promotes continuity of care. Documentation of client teaching supports quality improvement efforts and promotes third-party reimbursement.



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39. 2. It is a force that acts on or within a person that causes the person to behave in a particular way. 40. 4. involves acquiring skills that integrate mental and muscular activity 41. 4. A mild level of anxiety motivates learning, whereas a high level of anxiety prevents learning from occurring. 42. 3. Teaching complicated skills, such as learning to use a syringe, takes considerable practice but is developmentally appropriate. 43. 4. Outcomes describe a behavior that identifies the client’s ability to do something upon completion of teaching with realistic time frames.



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Chapter 26: Documentation and Informatics

1. anything written or printed that you rely on as record or proof for authorized persons 2. Joint Commission specifies guidelines for documentation. 3. a series of decision trees designed to cluster groups of clients together by diagnosis, surgical procedures, complications, co-morbidities, and age 4. a. client education on privacy protections b. ensuring client’s access to his or her medical records c. receiving client consent before information is released d. providing recourse if privacy protections are violated 5. requires documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning 6. is a confidential, permanent legal documentation of information relevant to a client’s health care 7. oral, written, or audiotaped exchanges between caregivers 8. form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver 9. an arrangement for services by another care provider 10. c 11. e 12. f 13. b 14. d 15. a 16. descriptive, objective information about what a nurse sees, hears, feels, and smells 17. the use of accepted abbreviations, symbols, and system of measures that are clear and easy to understand 18. containing appropriate and essential information 19. timely entries; immediate documentation of information as it is collected from the client 20. Communicate information in a logical order 21. j 22. c 23. i 24. f 25. h 26. g 27. e 28. b 29. a 30. d 31. c 32. e 33. b 34. a



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35. f 36. d 37. Provide only essential background information. 38. Identify the client’s nursing diagnosis or health care problems and their related causes. 39. Describe objective measurements or observations about condition and responses to health problem. 40. Share significant information about family members. 41. Continuously review ongoing discharge plan. 42. Relay to staff any significant changes in the way therapies are to be given. 43. Describe instructions given in teaching plan and the responses to instructions. 44. Evaluate results of nursing or medical care measures. 45. Be clear about priorities to which oncoming staff must attend. 46. The nurse includes when the call was made, who made it, who was called, to whom information was given, what information was given, a nd what information was received. 47. a. clearly determine the client’s name, room number, and diagnosis b. repeat any prescribed orders back to the physician c. use clarification questions d. write TO or VO, including the date and time, name of the client, and the complete order, and sign the physician name and the nurse e. follow agency policies f. physician must co-sign the order within the time frame required by the institution 48. a. client’s name, age, primary physician, and medical diagnosis b. summary of progress c. current health status d. allergies e. emergency code status f. family support g. current nursing diagnoses or problem and care plan h. any critical assessments or interventions to be completed i. need for any additional equipment 49. 4. should be most current and accurate continuous source of information about a client’s health care status 50. 4. When recording subjective data, document the client’s exact words within quotation marks whenever possible. 51. 2. An effective report describes each client’s health status and lets staff on the next shift know what care the clients will require. 52. 3. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. 53. 3. Do not erase, apply correction fluid, or scratch out errors made while recording; it may appear as if you were attempting to hide information or deface the record.



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Chapter 27: Self-Concept

1. Is an individual’s conceptualization of himself or herself. It is a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions. 2. a. sense of competency b. perceived reactions of others to one’s body c. ongoing perceptions and interpretations of the thoughts and feelings of others d. personal and professional relationships e. academic and employment-related identity f. personality characteristics g. perceptions of events h. mastery of prior experiences i. ethnic, racial, and spiritual identity 3. i 4. f 5. e 6. b 7. g 8. a 9. h 10. d 11. c 12. any real or perceived change that threatens identity, body image, or role performance. The individual’s perception of the stressor is the most important factor in d etermining his or her response. 13. g 14. d 15. f 16. c 17. h 18. b 19. e 20. a 21. thoughts and feelings about lifestyle, health, and illness 22. awareness of how one’s own nonverbal communication affects clients and families 23. personal values and expectations and how these affect clients 24. ability to convey a nonjudgmental attitude toward clients 25. preconceived attitudes toward cultural differences 26. focus on identity, body image, and role performance; actual and potential selfconcept stressors and coping patterns (nature, number, a nd intensity of stressors and internal and external resources) 27. if the person expresses a predominantly negative self-appraisal, including inability to handle situations or events and difficulty making decisions



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28. The client will discuss a minimum of 3 areas of her life where she is functioning well. Will be able to voice the recognition that losing her job is not reflective of her worth as a person. Will attend a support group for out-of-work professionals. 29. proper nutrition, regular exercise within client’s capabilities, adequate sleep and rest, stress-reducing practices 30. nonverbal behaviors indicating positive self-concept, statements of self-acceptance, and acceptance of change in appearance or function 31. 3. Adolescence is a particularly critical time when many variables affect self-concept and self-esteem. 32. 4. involves attitudes related to the body, including physical appearance, structure, or function, which is affected by cognitive and physical development as well as cultural and societal attitudes 33. 4. Certain behaviors become common depending on whether they are approved and reinforced. 34. 2. Attitudes toward body image can occur as a result of situational events such as the loss of or change in a body part. 35. Refer to Figure 27.5 in the text.



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Chapter 28: Sexuality

1. f 2. h 3. g 4. i 5. e 6. d 7. j 8. k 9. l 10. b 11. c 12. a 13. contaminated IV needles, anal intercourse, vaginal intercourse, oral-genital sex, and transfusion of blood products 14. a. impact of pregnancy and menstruation on sexuality b. discussing sexual issues 15. a. contraception b. abortion c. STD prevention 16. a. infertility b. sexual abuse c. personal and emotional conflicts d. sexual dysfunction 17. a. physical b. functional c. relationship d. lifestyle e. developmental factors f. self-esteem factors 18. Permission, limited, information, specific, suggestions, intensive, therapy 19. a. history of surgery of reproductive organs b. changes in the appearance or body image c. a history of or current physical or sexual abuse d. chronic illness or developmental milestones (puberty or menopause) 20. a. consistently use a water-soluble lubricant before sexual intercourse within 1 week b. discuss stressors that contribute to sexual dysfunction with partner within 2 weeks


Study Guide Answer Key c.

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identify alternative, satisfying, and acceptable sexual practices for self and partner within 4 weeks 21. a. contraception b. safe sex practices c. prevention of STDs d. women (regular breast self-exams, mammograms, Pap smears e. men (testicular exams) 22. Avoid alcohol and tobacco. 23. Eat well-balanced meals. 24. Plan sexual activity for times when couple feels rested. 25. Take pain medication if needed. 26. Use pillows and alternate positioning to enhance comfort. 27. Encourage touch, kissing, hugging, and other tactile stimulation. 28. Communicate your concerns and fears with partner. 29. Individuals experience major physical changes, the effects of drugs and treatments, emotional stress of a prognosis, concern about future functioning, and separation from others. 30. a. ask clients questions about risk factors, sexual concerns, and their level of satisfaction b. note behavioral cues 31. 4. The child identifies with the parent of the same sex and develops a complementary relationship with the parent of the opposite sex. 32. 4. Normal sexual changes occur as people age. 33. 1. Methods that are effective for contraception do not always reduce the risk of STDs. 34. Refer to Figure 28-2 in your text.



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Chapter 29: Spiritual Health

1. as an awareness of one’s inner self and a sense of connection to a higher being, nature, or to some purpose other than oneself 2. e 3. f 4. d 5. b 6. g 7. c 8. h 9. a 10. i 11. a. the strength of a client’s spirituality influences how he or she copes with sudden illness and how quickly he or she moves to recovery b. dependence on others for routine self-care needs often creates feelings of powerlessness; this along with the loss of a sense purpose in life impairs the ability to cope with alterations in functioning c. creates an uncertainty about what death means and thus makes clients susceptible to spiritual distress d. psychological phenomenon of people who either have been close to clinical death or have recovered after being declared dead. 12. Belief system, ethics or values, lifestyle, involvement in a spiritual community, education, future events 13. Individuals have some source of authority (supreme being, code of conduct, a specific religious leader, family or friends, oneself, or a combination) and guidance in their lives that lead them to choose and act on their beliefs. 14. Individuals who accept change in life, make decisions about their lives, and are able to forgive others in times of difficulty have a higher level of spiritual well-being. 15. People who are connected to themselves, others, nature, and God or another supreme being cope with the stress brought on by crisis and chronic illness. 16. When people are satisfied with life, more energy is available to deal with new difficulties and to resolve problems. 17. Remaining connected with their cultural heritage often helps clients define their place in the world and to express their spirituality. 18. a type of relationship that an individual has with other persons 19. Rituals include participation in worship, prayer, sacraments, fasting, singing, meditating, scripture reading, and making offerings or sacrifices. 20. Expression of spirituality is highly individual and includes showing an appreciation for life in the variety of things that people do, living in the moment and not worrying about tomorrow, appreciating nature, expressing love toward others, and being productive. 21. readiness for enhanced spiritual well-being; show a person’s ability to experience and integrate meaning and purpose in life through connectedness with self and others 22. spiritual distress; patterns reflect a person’s actual or potential dispiritedness



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23. risk for spiritual distress; have poor relationships, have experienced a recent loss, or who are suffering from some form of mental or physical illness 24. a. the client will express an acceptance of his or her illness b. the client reports the ability to rely on family members for support c. the client initiates social interactions with family and friends 25. giving attention, answering questions, listening and having a positive and encouraging (but realistic) attitude, being with rather then doing for 26. a. mobilizing hope for the nurse, as well as the client b. finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the client c. assisting the client in using social, emotional, and spiritual resources 27. serve as a human link connecting the client, the nurse, and the client’s lifestyle before an illness. The support system is a source of faith and hope and often is an important resource in conducting meaningful religious rituals. 28. Food and rituals are sometimes important to a person’s spirituality. 29. Plan care to allow time for religious readings, spiritual visitations, or attendance at religious services. 30. offers an opportunity to renew personal faith and belief in a higher being in a specific, focused way that is either highly ritualized and formal or spontaneous and informal 31. creates a relaxation that reduces daily stress, lowers blood pressure, slows the aging process, reduces pain, and enhances the function of the immune system 32. The nurse’s ability to enter into a therapeutic and spiritual relationship with the client will support a client during times of grief. 33. reveal the client developing an increased or restored sense of connectedness with family; maintaining, renewing, or reforming a sense of purpose in life and for a some a confidence and trust in a supreme being or power 34. 3. Must be able to practice the five pillars of Islam; health and spirituality are connected 35. 2. Their belief is not to kill any living creature. 36. 3. Muslims wash the body of the dead family member and wrap it in white cloth with the head turned to the right shoulder. 37. 2. The defining characteristics reveal patterns that reflect a person’s actual or potential dispiritedness. 38. 3. When clients use meditation in conjunction with their spiritual beliefs, they often report an increased spirituality that they commonly describe as experiencing the presence of power, force or energy, or what was perceived as God. 39. Figure 29-6 in the text



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Chapter 30: The Experience of Loss, Death, and Grief

1. m 2. o 3. n 4. p 5. g 6. l 7. b 8. k 9. j 10. e 11. i 12. d 13. h 14. f 15. a 16. 17. a. denial (a person acts as though nothing has happened and refuses to accept the fact of the loss) b. anger (adjustment to loss; person expresses resistance and feels intense anger at others) c. bargaining (make promises to God or loved ones) d. depression (sad, hopeless, and lonely) e. acceptance (person incorporates the loss into life and finds ways to move forward) 18. a. numbing (stunned or unreal) b. yearning and searching (for the lost person or object) c. disorganization and despair (endlessly examines how and why the loss occurred) d. reorganization (accepts change, assumes roles, acquires new skills) 19. a. accepts the reality of the loss b. works through the pain of grief c. adjusts to the environment in which the deceased is missing d. emotionally relocates the deceased and moves on with life 20. a. a grieving person comes to recognize the loss b. reacts to, experiences, and expresses the pain of separation c. reminiscing (telling and retelling stories) d. relinquishes old attachments e. readjusts and reinvests 21.


Study Guide Answer Key a. human development b. personal relationships c. nature of the loss d. coping strategies e. socioeconomic status f. culture and ethnicity g. spiritual and religious beliefs h. hope 22. client’s coping style, the nature of the family relationships, personal goals, cultural and spiritual beliefs, sources of hope, availability of support systems 23. a. death anxiety b. readiness for enhanced comfort c. ineffective denial d. fear e. hopelessness f. spiritual distress g. readiness for enhanced spiritual well-being 24. a. will participate in treatment decisions b. will be able to continue parental responsibilities in care of toddler c. will communicate treatment side effects or concerns to the health care team 25. is the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness, including care of the dying and bereavement follow-up for the family 26. a. affirm life and regard dying as a normal process b. neither hasten nor postpone death c. provide relief from pain and other distressing symptoms d. integrate psychological and spiritual aspects of client care e. offer a support system to help clients live as actively as possible until death f. offer a support system to help families cope g. enhance the quality of life 27. a. use therapeutic communication b. provide psychosocial care c. manage symptoms d. promote dignity and self-esteem e. maintain a comfortable and peaceful environment f. promote spiritual comfort and hope g. protect against abandonment and isolation h. support the grieving family i. assist with end-of-life decision making 28. help the survivor accept that the loss is real 29. support efforts to adjust to the loss, using a problem-solving approach 30. encourage establishment of new relationships


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31. allow time to grieve 32. interpret normal behavior 33. provide continuing support 34. be alert for signs of ineffective, harmful coping mechanisms 35. client and family are the unit of care; coordinate home care with access to available nursing home beds, control of symptoms, physician-directed services, provision of an interdisciplinary care team, medical and nursing services, bereavement follow-up, use of trained volunteers for frequent visitation, acceptance into the program based on need 36. provides information about who can legally give consent, which organs or tissues can be donated, associated costs, and how donation will affect burial or cremation 37. surgical dissection of a body after death to determine the cause and circumstances of death or discover the pathway of a disease 38. the care of the body after death, maintaining the integrity of rituals and mourning practices 39. talking about the loss without feeling overwhelmed, improved energy level, normalized sleep and dietary patterns, reorganization of life patterns, improved ability to make decisions, and finding it easier to be around people 40. return of a sense of humor and normal life patterns, renewed or new personal relationships, and decrease of inner pain 41. 1. Life changes are natural and often positive, which are learned as change always involves necessary losses. 42. 3. care of the terminally ill client and their families 43. 2. cushions and postpones awareness of the loss by trying to prevent it from happening 44. 3. is to help clients and families achieve the best possible quality of life, determining the goals of care and selection of the appropriate interventions 45. Figure 30-6 in your text



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Chapter 31: Stress and Coping

1. j 2. c 3. k 4. m 5. g 6. f 7. n 8. o 9. r 10. p 11. d 12. q 13. s 14. i 15. a 16. e 17. h 18. b 19. l 20. t 21. a. medulla oblongata b. the reticular formation c. the pituitary gland 22. views nursing as being responsible for developing interventions to prevent or reduce stressors on the client or to make them more bearable for the client (focus is on primary, secondary, and tertiary prevention) 23. increasing the level of well-being of an individual or group; primary, secondary, and tertiary prevention focus on avoiding negative events 24. arises frrm job changes (one’s own or family) and relocation 25. vary with life stage: children (relate to physical appearance), preadolescent (selfesteem issues), adolescent (identity), adults (major changes in life circumstances) 26. poverty and physical handicaps, loss of parents and caregivers (children), violence, homelessness 27. a. perception of the stressor b. maladaptive coping used c. adherence to healthy practices 28. a. grooming and hygiene b. gait c. characteristics of the handshake d. actions while sitting e. quality of speech



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f. eye contact g. the attitude of the client 29. verbalization of an inability to cope and an inability to ask for help 30. a. effective coping b. family coping c. caregiver emotional health d. psychosocial adjustment: life change 31. a. decrease stress-producing situations b. increase resistance to stress c. learn skills that reduce physiological response to stress 32. a. regular exercise b. support systems c. time management d. guided imagery and visualization e. progressive muscle relaxation f. assertiveness training g. journal writing h. stress management in the workplace 33. is a specific type of brief psychotherapy with prescribed steps; more directive 34. reports of feeling better when the stressor is gone; sleep patterns, appetite, and ability to concentrate have improved 35. 1. Stress is an experience a person is exposed to through a stimulus or stressor. 36. 1. Neurophysiological responses to stress function through negative feedback. 37. 1. alarm reaction, resistance stage, and the exhaustion stage 38. 3. The nurse helps the client make the mental connection between the stressful event and the client’s reaction to it. 39. Figure 31-8 in your text


Study Guide Answer Key Chapter 32: Vital Signs

1. The nurse may delegate the measurement of vital signs but is responsible for analyzing and interpreting their significance and select ap propriate interventions. 2. Equipment needs to be appropriate and functional. 3. Equipment needs to be based on the client’s condition and characteristics. 4. Know the client’s usual range of vital signs. 5. Know the client’s medical history. 6. Control or minimize environmental factors. 7. systematic approach 8. collaborate with health care providers to decide on the frequency 9. use measurements to determine the indications for medication administration 10. analyze the results 11. verify and communicate significant changes 12. develop a teaching plan 13. h 14. j 15. f 16. e 17. a 18. g 19. b 20. i 21. c 22. d 23. a. age b. exercise c. hormone level d. circadian rhythm e. stress f. environment 24. e 25. h 26. b 27. f 28. c 29. g 30. d 31. a 32. a. a constant body temperature continuously over 38 degrees C that has little fluctuation b. fever spikes interspersed with usual temperature levels c. fever spikes and falls without a return to normal d. periods of febrile episodes and periods of acceptable temperature values


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33. Examples Examples of answers can be found in the Box 32-5. 34. a. subtract 32 32 fr from the Fahrenheit re readin ding an and mul multtiply ply the the result by by 5/ 5/9 b. multiply ply the cen centtigra grade rea read ding by by 9/5 an and add add 32 to to th the pr produ oduct 35. a. risk for imbalanced body temperature b. hyperthermia c. hypothermia d. ineffective th thermoregulation 36. a. attaining fl fluid and el electrolyte ba balance wi within 24 24 hours b. obtaining ap appropriate cl clothing to to we wear in co cold we weather 37. very young and very old, trauma, trauma, stroke, diabetes, drug or alcohol alcohol intoxication, sepsis, inadequate home heating and shelter, fatigue, skin color, malnutrition, hypoxemia 38. a. have have imma immatture ure tempe emperratur aturee-co cont ntro roll mech mechan anis isms ms and and tempe empera ratu turres can can rise rise rapidly and are at risk for fluid-volume deficit b. b. ofte often n acco accom mpani panied ed by othe otherr all allergy ergy sym symptom ptomss such such as rash ash or prur prurit itus us 39. a. nonsteroidal drugs and corticosteroids b. b. tepid epid spong pongee bat baths hs,, bat bathi hing ng wit with al alcoho coholl wat water er solut olutiions, ons, appl apply ying ice pack packss to axillae and groin sites, and cooling fans 40. Move the client to a cooler environment, environment, remove excess body clothing, place cool wet towels over the skin, and use fans. 41. Remove wet clothes; clothes; wrap the client in blankets 42. After each intervention intervention measure the client’s client’s temperature to evaluate for change, palpate the skin, and assess the pulse and respirations. 43. a. radial b. apical 44. Refer to Table Table 32-2 for answers. answers. 45. a. rate, rhythm, strength, and equality b. rate and rhythm only 46. a. 120-160 b. 90-140 c. 80-110 d. 75-100 e. 60-90 f. 60-100 47. See answers answers in Table Table 32-4. 32-4. 48. abnormal elevated heart rate, rate, above 100 beats per minute in adults 49. slow rate, rate, below 60 beats per minute minute in adults



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50. an inefficient contraction of the the heart that fails to transmit a pulse wave to to the peripheral site; the difference between the apical and the radial pulse rate 51. An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm. 52. movement movement of gases in and out of the the lungs 53. the movement of oxygen oxygen and carbon dioxide between the alveoli and the the red blood cells 54. the distribution of red blood cells to and from the pulmonary capillaries 55. low levels levels of arterial arterial O2 56. a. active b. passive 57. See Table Table 32-11 for answers. answers. 58. a. 30-60 b. 30-50 c. 25-32 d. 20-30 e. 16-19 f. 12-20 59. Rate of breathing is regular but slow; < 12 breaths per minute. 60. Rate of breathing is regular but rapid; > 20 breaths per minute. 61. Respirations are labored, increased in in depth, and rate is > 20 breaths breaths per minute. 62. Respiration Respirationss cease for several several seconds. 63. Rate and depth of respirations respirations increase. increase. 64. Respiratory rate is abnormally low, and depth of ventilation ventilation is depressed. 65. Respiratory rate and depth are are irregular; alternating periods periods of apnea and hyperventilation. 66. abnormally deep, regular, and increased increased in rate 67. abnormally shallow for 2-3 2-3 breaths followed by irregular irregular period of apnea 68. The percent of hemoglobin that is bound with with oxygen in the arteries arteries is the percent of saturation of hemoglobin, usually between 95% and 100%. 69. the force exerted on the walls of an artery by the pulsing blood under pressure from the heart 70. peak of maximum pressure pressure when ejection ejection occurs 71. When the ventricles relax, the blood blood remaining in the arteries arteries exerts a minimum pressure. 72. the difference between systolic systolic and diastolic diastolic pressure 73. increases as a result of an increase in heart rate, rate, greater heart muscle contractility, contractility, or an increase in blood volume 74. is the resistance to to blood flow determined by the tone of vascular musculature and diameter of blood vessels 75. the volume of blood circulating circulating (increased or decreased) affects the blood blood pressure 76. the thickness affects the ease with which blood flows through blood vessels, determined by the hematocrit



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77. With reduced elasticity there there is greater resistance resistance to blood flow and the systemic systemic pressure rises (systolic pressure). 78. a. age b. stress c. ethnicity d. gender e. daily variations f. medications g. activity and weight h. smoking 79. a. 40 (mean) b. 85/54 c. 95/65 d. 105/65 e. 110/65 f. 120/75 g. <120/80 80. See Table 32-8. 81. family history, obesity, cigarette smoking, heavy alcohol consumption, high sodium, sedentary lifestyle, exposure to continuous stress, diabetics, older, African Americans 82. dehydrated, anemic, experienced prolonged bed rest, recent blood blood loss, medications 83. st 1 – clear, rhythmical tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure) 2nd – blowing or swishing sound as the cuff deflates 3rd – a crisper and more intense tapping 4th – muffled and low-pitched as the cuff is further deflated (diastolic pressure in infants and children) 5th – the disappearance of sound soun d (diastolic pressure in adolescents and adults) 84. palpation technique; usually occurs between the first and second second Korotkoff sounds 85. See Table Table 32-17 for answers. answers. 86. See Table Table 32-18 for answers. answers. 87. 4. The skin regulates regulates the temperature temperature through insulation of the body, vasoconstriction, and temperature sensation. 88. 3. is the transfer of heat from one object to to another with direct contact (solids, (solids, liquids, and gases) 89. 3. Victims Victims of heat stroke stroke do not sweat. sweat. 90. 2. 156 is the onset of the first Korotkoff sound (systolic (systolic pressure) and 88 is the fifth sound that corresponds with the diastolic pressure.



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Chapter 33: Health Assessment and Physical Examination

1. a. gather baseline data about the client’s health status b. supplement, confirm, or refute data c. confirm and identify nursing diagnoses d. make clinical judgments about a client’s changing health status e. evaluate the outcomes of care 2. a. adequate lighting is available b. position and expose body parts to be viewed c. inspect each area for size, shape, color, symmetry, position, and abnormalities d. compare each area inspected with the same area on the opposite side e. use additional lighting to inspect body cavities f. do not hurry; pay attention to detail 3. involves the use of the hands to touch body parts to make sensitive assessments 4. produces a vibration that travels through the body tissues, which determines the location, size, and density of underlying structures to verify abnormalities assessed 5. involves listening to sounds the body makes with the use of a stethoscope 6. a. infection control b. environment c. equipment d. physical preparation of the client e. psychological preparation of the client 7. a. gather all or part of the histories of infants and children from parents b. perform the examination in a nonthreatening area c. offer support to the parents during the examination d. call children by their first name and address the parents as Mr. and Mrs. e. use open-ended questions to allow parents to share more information f. treat adolescents as adults g. confidentiality for adolescents; speak alone with them 8. a. do not stereotype b. sensory or physical limitations (more time) c. adequate space is needed d. use patience; allow for pauses e. certain types of information may be stressful to give f. perform the exam near bathroom facilities g. be alert for signs of increasing fatigue 9. gender and race 10. age 11. signs of distress 12. body type 13. posture



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14. 14. gait gait 15. body movements movements 16. hygiene hygiene and groomi grooming ng 17. 17. dres dresss 18. body odor 19. affect and mood 20. 20. speec speech h 21. physical injury or neglect are signs of possible possible abuse (evidence of malnutrition malnutrition or presence of bruising); fear of the spouse or partner, caregiver, or parent 22. C – have you ever felt the need to cut down on your use? A – have people annoyed you by criticizing your use? G – have you ever felt bad or guilty about your use? E – have you ever e ver used or had a drink first thing in the morning as an eye-opener to steady your nerves or feel normal? 23. a. need to weigh clients at the same time of day b. on the same scale c. in the the sam samee clot clothe hess to to al allow an obje object ctiive com compari pariso son n of of subse ubsequ quen entt wei weight ghts 24. trauma to skin during care, exposure to pressure during immobilization, immobilization, reaction to various medications , neurologically impaired, chronically ill and orthopedic clients, diminished mental status, poor tissue oxygenation, low cardiac o utput, or inadequate nutrition 25. aggressive aggressive form form of skin cancer cancer 26. discolored skin that occurs unevenly, especially in the older adult 27. Answers Answers can be found in Table Table 33-10. 28. a. eczema b. dermatitis 29. hardene hardened d 30. skin’s skin’s elasticit elasticity y 31. areas of the skin swollen swollen or edematous form a buildup buildup of fluid in the tissues tissues 32. thickening thickening of the skin skin 33. ruby-red ruby-red papules papules 34-42. Answers can be found in Box 33-8. 43. a. pediculus humanus capitis (head lice) b. pediculus humanus corporis (body lice) c. pediculus pubis (crab lice) 44. change in the angle between nail and nail base, softening and flattening and enlargement of the fingertips 45. transverse depressions in nails 46. concave curves 47. splinter hemorrhages 48. inflammation of the skin at base of the nail 49. congenital anomaly or the buildup of cerebrospinal fluid in the ventricles



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50. enlarged jaws and facial bones 51. a refractive error causing farsightedness 52. a refractive error causing nearsightedness 53. impaired near vision in middle-age and an d older adults, caused by loss of elasticity of the lens 54. noninflammatory eye disorder resulting from changes in retinal blood vessels 55. congenital condition in which both eyes do not focus on an object simultaneously 56. increased opacity of the lens 57. intraocular structural damage resulting from increased intraocular pressure 58. blurred central vision often occurring suddenly, caused by progressive degeneration of the center of the retina 59. a. visual acuity b. visual fields c. extraocular movements d. external eye structures e. internal eye structures 60. a. position and alignment b. eyebrows c. eyelids d. lacrimal apparatus e. conjunctivae f. sclerae g. pupils and irises 61. bulging eyes 62. lid margins that turn out 63. lid margins that turn in 64. presence of redness, which indicates and allergy or an infection 65. a thin white ring along the margin of the iris 66. P 66. P upils E upils E qual, R qual, Round, ound, R Reactive eactive to L to Light ight and A and Accommodation ccommodation 67. retina, choroids, optic nerve disc, macula, fovea centralis, and retinal vessels 68. a. external (a (auricle, ou outer ea ear ca canal an and ty tympanic me membrane) b. middle (3 bony ossicles) c. inner ea ear (c (cochlea, ve vestibule, an and se semicircular ca canals) 69. a. enter the external ear, pass through the outer ear canal b. waves reach the tympanic membrane (vibrate) c. vibr vibrat atio ions ns are are tr transm ansmiitted ted thr throu ough gh the the mid middl dlee ear ear by the the bon bony y occi occicu cullar chai chain n to the oval window of the inner ear d. cochlea receive the vibration e. nerve impulses from the cochlea travel to the audit ditory ory nerve (8th) and to the cerebral cortex 70. a. conduction



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b. sensorineural c. mixed 71. lateralization of sound equally in both ears 72. comparison of air and bone conduction (AC>BC) 73. skin breakdown, characterized by redness and skin sloughing 74. tumor-like growths 75. thick white patches that are often precancerous lesions seen in heavy smokers and alcoholics 76. swollen, tortuous veins that are common in the older adult 77. extra bony growth between the 2 palates 78. neck muscles, lymph nodes of the head and neck, n eck, carotid arteries, jugular veins, thyroid gland, and trachea 79. sound waves that create vibrations that can be palpated externally 80. air movement through smaller airways that is soft, breezy, and low-pitched 81. air moving through larger airways that is blowing, medium-pitched, and intensity 82. air moving through trachea which is loud and high-pitched, with w ith hollow quality 83. Answers can be found in Table 33-22. 84. apex touching the anterior chest wall at approximately the fourth to fifth intercostal space, just medial to the left midclavicular line 85. Mitral and tricuspid valve closure causes the first heart sound. 86. Aortic and pulmonic valve closure causes the second heart sound. 87. rapid ventricular filling 88. Atria contract to enhance ventricular filling. 89. lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch 90. second intercostal space on the right 91. left second intercostal space 92. left third intercostal space 93. Fourth or fifth intercostal space along the sternum 94. Fifth intercostal space just to the left of the sternum, left midclavicular line 95. tip of the sternum 96. sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase 97. a. ausc auscul ulta tatte al all val valve ve area areass for for plac placem emen entt in in the the card cardiiac cycl cyclee (ti (timi ming ng), ), wher wheree best heard (location) and radiation, loudness, p itch and quality b. between S1 S1 an and S2 S2 (systolic) and S2 an and S1 (diastolic) c. location is not necessarily over the valves d. assess for radiation e. intensity or loudness and record in grading 1-6 f. low-pitched murmur best heard with the diaphragm 98. caused by a drop in heart rate and blood pressure 99. absent pulse wave (blockage) 100. diminished or unequal carotid pulsations 101. blood passing through a narrowed section, creating turbulence 102.


Study Guide Answer Key a. b. c.

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semi-Fowler’s position expose the neck; align the head lean client back into a supine position; level of venous pulsations begin to rise as the patient reaches 45-degree angle d. use 2 rulers e. repeat the same measurement on the other side 103. Refer to Table 33-26 for the answers. 104. Inspect the calves for localized redness, tenderness, and swelling over vein sites. 105. a. BSE monthly b. women aged 20 years and older need to report any breast changes c. clinical breast exam every 3 years (20-40) and yearly over the age of 40 d. family history: need a yearly exam e. mammogram: age 40 annually (asymptomatic) f. additional testing (increased risks) 106. spreading to the nodes 107. bilateral lumpy, painful breast, sometimes with nipple discharge 108. stretch marks 109. protusion of abdominal organs through the muscle wall 110. swelling by intestinal gas, tumor, or fluid in the abdominal cavity 111. movement of contents through the intestines, which is a normal function of the small and large intestine 112. absent sounds that may indicate a lack of peristalsis 113. growling sounds, which are hyperactive bowel sounds 114. occurs in clients with peritoneal irritation 115. localized dilation of a vessel wall 116. syphilitic lesions, which appear as small,open ulcers that d rain serous material 117. a test for cervical and vaginal cancer 118. a painless enlargement of one testis and the appearance of a palpable, small, hard lump on the side of the testicle 119. to detect colorectal cancer in the early stages and prostatic tumors 120. hunchback, an exaggeration of the posterior curvature of the thoracic spine 121. swayback, an increased lumbar curvature 122. lateral spinal curvature 123. metabolic bone disease that causes a decrease in quality and quantity of bone 124. measures the precise degree of motion in a particular joint 125. movement decreasing angle between 2 adjoining bones 126. increasing angle between 2 adjoining bones 127. beyond its normal resting extended position 128. that the frontal or ventral surfaces face downward 129. front or ventral surface faces upward 130. away from the midline 131. toward the midline 132. rotation of the joint inward 133. rotation of the joint outward 134. turning of the body part away from the midline



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135. turning the body part toward the midline 136. flexion of toes and foot upward 137. bending of toes and foot downward 138. increased muscle tone 139. a muscle with little tone 140. a muscle reduced in size that feels soft and boggy 141. measures orientation and cognitive function 142. confusion, disorientation, and restlessness 143. an objective measurement of consciousness on a numerical scale over time 144. a. a person cannot understand written or verbal speech b. a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate 145. a. olfactory b. optic c. oculomotor d. trochlear e. trigeminal f. abducens g. facial h. auditory i. glossopharyngeal j. vagus k. spinal accessory l. hypoglossal 146. pain, temperature, position, vibration, and crude and finely localized touch 147. pain, light touch, vibration, position, 2-point discrimination 148. Muscular activity maintains balance and equilibrium and helps to control posture. 149. a. deep tendon reflexes (biceps, triceps, patellar, Achilles) b. cutaneous reflexes (plantar, gluteal, abdominal) 150. 4. A thorough explanation of the purpose and steps of each assessment lets clients know what to expect and what to do so that they can cooperate. 151. 3. normally the skin lifts easily and snaps back immediately to its resting position; the back of the hand is not the best place to test for turgor 152. 3. circumscribed elevation of skin filled with serous fluid, smaller than 1 cm 153. 2. Use a systematic pattern when comparing the right and left sides. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite of the body. 154. 3. high-velocity airflow through severely narrowed or obstructed airway 155. 4. After the ventricles empty, ventricular pressure falls below that in the aorta and pulmonary artery, allowing the valves to close and causing the second heart sound.



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Chapter 34: Infection Prevention and Control

1. d 2. m 3. o 4. l 5. g 6. n 7. k 8. p 9. a 10. f 11. j 12. b 13. e 14. h 15. c 16. i 17. a. an infectious agent or pathogen b. a reservoir or source c. a portal of exit from the reservoir d. a mode of transmission e. a portal of entry to a host f. a susceptible host 18. direct – person-to-person or physical source and susceptible host 19. indirect – personal contact of susceptible host with contaminated inanimate object 20. droplet – large particles that travel up to 3 ft and come in contact with the host 21. airborne – droplets that suspend in air 22. vehicles –contaminated items 23. vector – internal and external transmissions 24. depends on the individual degree of resistance to a pathogen (immune response) 25. a. wound infection; patient experiences localized symptom b. an infection that affects the entire body instead of just a single organ 26. The body contains microorganisms that reside on the surface and deep layers of the skin, in saliva and oral mucosa, and the intestinal walls and GU tract that maintain health. 27. The skin, mouth, eyes, respiratory tract, urinary tract, GU tract, and vagina have unique defenses against infection. 28. the body’s response to injury, infection, or irritation; is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury 29. acute inflammation: rapid vasodilatation that causes redness at the site and localized warmth allowing phagocytosis to occur 30. accumulation of fluid and dead tissue cells and WBCs forms at the site. Exudate may be serous, sanguineous, or purulent.



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31. Healing involves the defensive, reconstructive, and maturative stages. 32. comes from microorganisms outside the individual that do not exist in normal floras 33. occurs when part of the client’s flora becomes altered and an overgrowth results 34. a. urinary tract b. surgical or traumatic wounds c. respiratory tract d. bloodstream 35. COPD, heart disease, diabetes 36. exposure to communicable/infectious disease, use of IV drugs/substances 37. miner, unemployed, homeless 38. invasive radiology, transplant 39. sickle cell disease, diabetes 40. West Nile virus, SARS, avian flu, hantavirus 41. fractures, internal bleeding 42. obesity, anorexia 43. See Table 34-5 for answers. 44. a. risk for infection b. imbalanced nutrition c. impaired oral mucous membrane d. impaired skin integrity e. ineffective tissue perfusion f. impaired tissue integrity 45. a. preventing exposure to infectious organisms b. controlling or reducing the extent of infection c. maintaining resistance to infection d. educating the client and family about infection control techniques 46. strengthen their defenses a. nutrition b. immunizations c. personal hygiene d. regular rest and exercise e. eliminate reservoirs of infection f. control portals of exit and entry 47. the absence of pathogenic microorganisms; the technique refers to the practices/procedures that assist in reducing the risk for infection 48. clean technique: hand hygiene, using clean gloves, cleaning the environment routinely 49. removal of all soil (organic and inorganic material) from objects and surfaces with the use of water and mechanical action with detergents or enzymatic products 50. a process that eliminates many or all microorganisms with the exception of bacterial spores from inanimate objects 51. the complete elimination or destruction of all microorganisms, including spores



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52. need to eliminate sources of body fluids, drainage, or solutions that may harbor organisms; discard contaminated articles 53. teach patient respiratory hygiene 54. prevent transmission of organisms through indirect and direct contact –use disinfectant on stethoscopes, soiled linens,handling of catheters and drainage sets, IV tubing, wound cleansing 55. applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis 56. is designed for all clients in all settings regardless of the diagnosis; apply to contact with blood, body fluid, nonintact skin, and mucous membranes 57. based on the mode of transmission of disease that is termed airborne; droplet; contact; protective environment 58. gowns – to prevent soiling clothes during contact with the client 59. masks – when you anticipate splashing or spraying of blood or bloody fluid into the face; droplet or airborne precautions 60. eyewear – procedures that generate splash or splatter 61. gloves – to prevent the transmission of pathogens by direct and indirect contact 62. a. cultures b. pathological wastes c. blood and blood products d. sharps e. selected isolation material 63. a. provide staff and client education b. develop and review infection prevention and control policies and procedures c. recommend appropriate isolation procedures d. screen client records e. consult with health departments f. gather statistics regarding the epidemiology g. notify the public health department of incidences of communicable diseases h. consult with all departments to investigate unusual events or clusters i. monitor antibiotic-resistant organisms 64. a. during procedures that require intentional perforation of the client’s skin b. when the skin’s integrity is broken c. during procedures that involve insertion of catheters 65. A sterile object remains sterile only when touched by another sterile object. 66. Place only sterile objects on a sterile field 67. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. 68. A sterile object or field becomes contaminated by prolonged exposure to air. 69. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 70. Because fluid flows in the direction of gravity, a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the object’s surface.



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71. The edges of a sterile field or container are considered to be contaminated. 72. a. assemble all equipment b. surgical scrub c. donning caps, masks, and eyewear d. preparing a sterile field e. open sterile packages on a flat surface f. pouring sterile solutions g. applying sterile gloves h. donning a sterile gown 73. a. monitor clients postoperatively –surgical sites, invasive sites, respiratory tract, and urinary tract b. all invasive and surgical sites for swelling, erythema, or purulent drainage c. monitor breath sounds d. review lab results 74. 3. Infection occurs in a cycle that depends on the presence of certain elements. 75. 1. The incubation period is the interval between the entrance of the pathogen into the body and appearance of first symptoms. 76. 4. occurs when part of the client’s flora becomes altered and an overgrowth results 77. 1. If moisture leaks through a sterile package’s protective covering, organisms can travel to the sterile object. 78. 1. Clients who are transported outside of their rooms need to wear a surgical mask to protect other clients and personnel.



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Chapter 35: Medication Administration

1. a. is to protect the health of the people by ensuring that medications are safe and effective. Currently the FDA ensures that all medications undergo vigorous testing before they are sold. b. conform to federal legislation but also have additional controls such as alcohol and tobacco. c. individual policies to meet federal and state regulations. d. define the scope of a nurse’s professional functions and responsibilities. 2. provides an exact description of the medication’s composition and molecular structure 3. manufacturer who first develops the medication, which becomes the official name 4. the manufacturer has trademarked the medication’s name 5. indicates the effect of the medication on a body system, the symptoms the medication relieves, or the medication’s desired effect 6. determines its route of administration 7. is the study of how medications enter the body, reach their site of action, metabolize, and exit the body 8. refers to the passage of medication molecules into the blood from the site of administration 9. a. route of administration b. ability of the medication to dissolve c. blood flow to the site of administration d. body surface area e. lipid solubility 10. a. circulation b. membrane permeability c. protein binding 11. occurs under the influence of enzymes that detoxify, degrade, and remove biologically active chemicals, mostly in the liver 12. the kidneys; when renal function declines, a client is at risk for medication toxicity 13. is the expected or predictable physiological response to a medication 14. are the unintended, secondary effects a medication predictably will cause 15. are severe responses to medication 16. develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion 17. unpredictable effects in which a client overreacts or underreacts to a medication or has a reaction different from normal 18. are predictable responses to a medication 19. allergic reactions that are life-threatening and characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath 20. when one medication modifies the action of another medication 21. The combined effect of the 2 medications is greater than the effect of the medications when given separately. 22. constant blood level within a safe therapeutic range 23. highest serum concentration 24. is the time it takes for excretion processes to lower the serum medication concentration by half 25. time it takes after a medication is administered for it to produce a response 26. time it takes for a medication to reach its highest effective concentration



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27. minimum blood serum concentration of medication reached just before the next scheduled dose 28. time during which the medication is present in concentration great enough to produce a response 29. blood serum concentration of a medication reached and maintained after repeated fixed doses 30. a. oral b. buccal c. sublingual 31. a. intradermal b. subcutaneous c. intramuscular d. intravenous 32. administered in the epidural space via a catheter, usually used for post-op analgesia 33. a catheter that is in the subarachnoid space or one of the ventricles of the brain 34. infusion of medication directly into the bone marrow, commonly used in infants and toddlers 35. into the peritoneal cavity such as chemotherapeutic agents, insulin, and antibiotics 36. directly into the pleural space, commonly chemotherapeutics 37. directly into the arteries 38. injection directly into the cardiac tissue 39. injection of a medication into a joint 40. a. directly applying a liquid or ointment b. inserting a medication into a body cavity c. instilling fluid into a body cavity d. irrigating a body cavity e. spraying 41. They are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue. 42. a. metric b. apothecary c. household 43. given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid 44. dose ordered/dose on hand x amount on hand = amount to administer 45. child’s dose = surface of child/1.7 m2 x normal adult dose 46. if the order is given verbally to the nurse by the provider 47. is carried out until the prescriber cancels it by another order or until a prescribed number of days elapse 48. a medication that is given only when a client requires it 49. a medication that is given only once at a specified time 50. single dose of a medication to be given immediately and only once 51. is used when a client needs a medication quickly but not right away; nurse has up to 90 minutes to administer 52. a. unit dose b. automated medication dispensing systems (AMDS) 53. inaccurate prescribing, administration of the wrong medicine, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication 54. a. verify b. clarify c. reconcile d. transmit 55. a. the right medication b. the right dose c. the right client d. the right route e. the right time f. the right documentation 56. a. be informed of the medication’s name, purpose, action, and potential undesired effects b. refuse a medication regardless of the consequences c. have qualified nurses or physicians assess a medication history d. be properly advised of the experimental nature of medication therapy and give written consent e. receive labeled medications



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safely without discomfort f. receive appropriate supportive therapy g. not receive unnecessary medications h. be informed if medications are a part of a research study 57. a. history b. history of allergies c. medication data d. diet history e. client’s perceptual coordination problems f. client’s current condition g. client’s attitude about medication use h. client’s knowledge and understanding of medication therapy i. client’s learning needs 58. anxiety 59. health maintenance, ineffective 60. health-seeking behaviors 61. deficient knowledge 62. noncompliance 63. disturbed visual sensory perception 64. impaired swallowing 65. effective therapeutic regimen management 66. ineffective therapeutic regimen management 67. a. will verbalize understanding of desired effects and adverse effects of medications b. will state signs, symptoms, and treatment of hypoglycemia c. to monitor blood sugar to determine if medication is appropriate to take d. establish a daily routine that will coordinate timing of medication with meal times 68. health beliefs, personal motivations, socioeconomic factors, and habits 69. a. client’s full name b. date and time that the order is written c. medication name d. dose e. route of administration f. time and frequency of administration g, signature of provider 70. the name of the medication, dose, route, and the exact time of administration and site 71. a. when clients need to take several medications to treat their illnesses b. happens when people take more medications then needed 72. a. client and family understand medication therapy b. client safely self-administers medications 73. a. Determine the client’s ability to swallow. b. Assess the client’s cough. c. Determine the presence of a gag reflex. d. Prepare oral medications in the form that is easiest to swallow. e. Allow the client to self-administer medications if possible. f. If the client has unilateral weakness, place the medication in the stronger side of the mouth. g. Administer pills one at a time, ensuring that each medication is properly swallowed before the next one is introduced. h. Thicken regular liquids or offer fruit nectars if the client cannot tolerate thin liquids. i. Avoid straws because they decrease the control the client has over volume intake, which increases the risk of aspiration. j. Have client hold cup and drink from cup if possible. k. Time medications to coincide with mealtimes or when the client is well-rested and awake if possible. l. Administer medications using another route if risk of aspiration is severe.



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74. a. document where the medication was placed on the MAR b. assess if patient has an existing patch before application c. assess the skin thoroughly d. medication history/ reconciling medications e. apply a noticeable label to the patch f. document removal of medication on the MAR 75. decongestant spray or drops 76. a. avoid instilling any eye medication directly onto the cornea b. avoid touching the eyelids or other eye structures with eye droppers or ointment tubes c. use medication only for the client’s affected eye d. never allow a client to use another client’s eye medications 77. vertigo, dizziness, nausea 78. suppositories, foam, jellies, or creams 79. exerting local effects (promoting defecation) or systemic effects (reducing nausea) 80. a. delivers a measured dose of medication with each push of a canister often used with a spacer b. hold dry, powdered medication and create an aerosol when the client inhales through a reservoir that contains the medication 81. Draw medication from ampule quickly; do not allow to stand open. 82. Avoid letting needle touch contaminated surface. 83. Avoid touching length of plunger or inner part of barrel. 84. Prepare skin, use friction and a circular motion while cleaning with an antiseptic swab, and start from the center and move outward. 85. a. the client’s size and weight b. type of tissue into which the medication is to be injected 86. a. contain single doses of medications in a liquid b. is a single dose or multidose container with a rubber seal at the top (closed system) 87. a. do not contaminate one medication with another b. ensure that the final dose is accurate c. maintain aseptic technique 88. rate of action (rapid, short, intermediate, and long-acting); each has a different onset, peak, and duration of action 89. a. need to maintain their individual routine when preparing and administering their insulin b. do not mix insulin with any other medication or diluents c. never mix insulin glargine or insulin detemir with other types of insulin d. inject rapid-acting insulin mixed with NPH within 15 minutes before a meal e. do not mix short-acting and lente insulins unless the blood glucose levels are currently under control with this mixture f. do not mix phosphate-buffered insulins with lente insulins 90. a. use a sharp beveled needle in the smallest suitable length and gauge b. position the client as comfortably as possible to reduce muscle tension c. select the proper injection site d. divert the client’s attention from the injection e. insert the needle quickly and smoothly f. hold the syringe while the needle remains in tissues g. inject the medication slowly and steadily 91. the outer posterior aspect of the upper arms, the abdomen (below the costal margins to the iliac crests), and the anterior aspects of the thighs 92. 0.5 to 1 ml 93. 25-gauge, 5/8 inch needle inserted at a 45-degree angle or a ½ inch needle inserted at a 90-degree angle 94. 90 degrees 95. a. 3 ml into a large muscle b. 2 ml c. 1 ml



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96. lacks major nerves and blood vessels; rapid absorption; frequently used in infants, older children, and toddlers (immunizations) 97. deep site away from nerves and blood vessels, less chance of contamination, easily identified landmarks, preferred site for medications 98. easily accessible but muscle not well developed, use small amounts, not used in infants or children, potential for injury to radial and ulnar nerves, immunizations for children, recommended site for hepatitis B and rabies injections 99. minimizes local skin irritation by sealing the medication in muscle tissue 100. skin testing, injected into the dermis where medication is absorbed slowly 101. a. as mixtures within large volumes of IV fluids b. injection of a bolus or small volume of medication c. piggyback infusion 102. a. fast-acting medications must be delivered quickly b. constant therapeutic blood levels 103. a. most dangerous method because there is not time to correct errors b. a bolus may cause direct irritation to the lining of blood vessels 104. a. it reduces risk for rapid-infusion by IV push b. allows for administration of medications that are stable for a limited time in solution c. it allows for control of IV fluid intake 105. a small (25-250 ml) IV bag connected to short tubing lines that connects to the upper Y port of a primary infusion line 106. small (25-100 ml) IV bag connected to a short tubing line to the lower Y port of a primary infusion 107. small (50-150 ml) containers that attach below the primary infusion bag 108. battery-operated and allows medications to be given in very small amounts of fluid (5-60 ml) 109. a. cost-saving, convenience, increased mobility, safety, and comfort for the client 110. 3. definition of pharmacokinetics 111. 1. absorption refers to the passage of medication molecules into the blood from the site of administration 112. 1. definition of onset 113. 1. is an oral route 114. 2. child’s dose = surface of child/1.7 m 2 x normal adult dose 115. 2. if mixing rapid- or short-acting insulin with intermediate or long-acting insulin, take insulin syringe and aspirate volume of air eq uivalent to the dose of insulin to be withdrawn from the long-acting insulin first.



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Chapter 36: Complementary and Alternative Therapies

1. are therapies used in addition to conventional treatment recommended by the client’s provider 2. include the same interventions as complementary but frequently become the primary treatment that replaces allopathic medical care 3. a. Acupuncture: A traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of lines or channels, called meridians. Direct needle manipulation of energetic meridians influences deeper internal organs by redirecting Chi. b. Ayurveda: Traditional Hindu system of medicine practiced in India since the first century A.D. A combination of remedies such as herbs, purgative, and rubbing oils that treat disease. c. Homeopathic medicine: System of medical treatments based on the theory that certain diseases can be cured by giving small doses of substances that in a healthy person would produce symptoms like those of the disease. Prescribed substances called remedies are made from naturally occurring plant, animal, or mineral substances. d. Latin American practices: Curanderismo medical system, which includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses. e. Native American practices: Therapies include sweating and purging, herbal remedies, and shamanic healing (healer makes contact with spirits to ask their direction in bringing healing to people). f. Naturopathic medicine: System of therapeutics based on natural foods, light, warmth, massage, fresh air, regular exercise, and avoidance of medications. Recognizes inherent healing ability of the bod y. Treatments integrate traditional natural therapies with modern diagnostic science; includes botanical (plant) medicine. g. Traditional Chinese medicine: Set of systematic techniques and methods including acupuncture, herbal medicines, massage, acupressure, moxibustion (use of heat from burning herbs), Qigong (balancing energy flow through body movement), and oriental massage. Fundamental concepts from Taoism, Confucianism, and Buddhism. 4. a. the “Zone”: Dietary program that requires eating protein, carbohydrates, and fat in a 30:40:30 ratio: 30% of calories from protein, 40% from carbohydrates, and 30% from fat. Used to balance insulin and other hormones for optimal health. b. macrobiotic diet: Predominantly a vegan diet (no animal products except fish). Initially used in the management of a variety of can cers. Emphasis placed on whole cereal grains, vegetables, and unprocessed foods. c. orthomolecular medicine: Increased intake of nutrients such as vitamin C and beta-carotene. Diet treats cancer, schizophrenia, autism, and certain chronic diseases such as hypercholesterolemia and coronary artery disease. d. European phytomedicines: Products developed under strict quality control in sophisticated pharmaceutical factories, packaged professionally in tablets or capsules.



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Examples of well-studied herbal medicines include gingko biloba, milk thistle, and bilberry. Herbs have a wide variety of uses. e. traditional Chinese herbal medicines: Over 50,000 medicinal plant species, many of which have been studied extensively. Herbs considered the backbone of medicine. f. Ayurvedic herbs: Traditional Hindu system of herbs used for over 2000 years. 5. a. acupressure: Therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function. b. chiropractic medicine: System of therapy that involves manipulation of the spinal column and includes physiotherapy and diet therapy. c. Feldenkrais method: Alternative therapy based on establishment of good self-image through awareness and correction of body movements. Technique integrates the understanding of the physics of the body’s movement patterns with an awareness of the way people learn to move, behave, and interact. d. Tai chi: Technique that incorporates breath, movement, and meditation to cleanse, strengthen, and circulate vital life energy and blood. Therapy stimulates the immune system and maintains external and internal balance. e. massage therapy: Manipulation of soft tissue through stroking, rubbing, or kneading to increase circulation, improve muscle tone, and relaxation. f. simple touch: Touching the client in appropriate and gentle ways to make connection, display acceptance, and give appreciation. 6. a. art therapy: Use of art to reconcile emotional conflicts, foster self-awareness, and express clients’ unspoken and frequently unconscious concerns about their disease. b. biofeedback: A process providing a person with visual or auditory information about autonomic physiological functions of the body, such as muscle tension, skin temperature, and brain wave activity, through the use of instruments. c. dance therapy: Intimate and powerful medium for therapy because it is a direct expression of the mind and body. Therapy treats persons with social, emotional, cognitive, or physical problems. d. breathwork: Using any of a variety of breathing patterns to relax, invigorate, or open emotional channels. e. guided imagery: Therapeutic technique for treating pathological conditions by concentrating on an image or series of images. f. meditation: Self-directed practice for relaxing the body and calming the mind using focused rhythmic breathing g. music therapy: Uses music to address physical, psychological, cognitive, and social needs of individuals with disabilities and illnesses. Therapy improves physical movement and/or communication, develops emotional expression, evokes memories, and distracts people who are in pain. h. healing intention: Variety of techniques used in multiple cultures that incorporate caring, compassion, love, or empathy with the target of prayer. i. psychotherapy: Treatment of emotional and mental disorders by psychological techniques.


Study Guide Answer Key j.

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yoga: Discipline that focuses on the body’s musculature, posture, breathing mechanisms, and consciousness. Goal of yoga is attainment of physical and mental well-being through mastery of body achieved through exercise, holding of postures, proper breathing, and meditation.

7. a. biofield: intended to affect energy fields that purportedly surround and penetrate the human body. b. bioelectromagnetic-based therapies: involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields. 8. increased heart and respiratory rates, tightened muscles, increased metabolic rate, general sense of fear, nervousness, irritability and negative mood 9. is the state of generalized decreased cognitive, physiological, and/or behavioral arousal 10. teaches the individual how to effectively rest and reduce tension in the body 11. teaches the individual to relax individual muscle groups passively 12. lower heart rate and blood pressure, decrease muscle tension, improve well-being, and reduce symptom distress 13. fearing loss of control, feeling like they are floating, and experiencing induced anxiety related to these feelings 14. is any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus 15. anxiety states, chronic bereavement, chronic fatigue syndrome, chronic pain, drug abuse, hypertension, irritability, low self-esteem, mild depression, sleep disorders 16. contraindicated for people who have a strong fear of losing control or who are hypersensitive; medication use 17. visualization techniques that use the conscious mind to create mental images to stimulate physical changes in the body, improve p erceived well-being, and/or enhance self-awareness 18. one form of self-directed imagery that is based on the principle of mind-body connectivity 19. used to visualize cancer cells being destroyed by cells of the immune system, control or relieve pain, and achieve calmness and serenity 20. a group of therapeutic procedures that uses electronic or electromechanical instruments to measure, process, and provide information to persons about their neuromuscular and ANS activity 21. treating migraines, strokes, and a variety of gastrointestinal and urinary tract disorders 22. Repressed emotions or feelings are sometimes uncovered, and the client has difficulty coping. 23. involves the practitioner scanning the body of the client and diagnosing areas of accumulated tensions and redirecting these energies to bring the person back into balance 24. a. the process whereby the practitioner becomes aware and fully present during the entire treatment b. moves their hands in a rhythmic and symmetrical movement from



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head to toes, noticing the quality of energy flow c. facilitates the symmetrical and rhythmical flow of energy through the body d. directs and balances the energy, attempting to rebalance the energy flow e. reassessment of the energy field 25. increased Hb levels, reduces anxiety levels, reduces headaches, improves mood 26. contraindicated in persons who are sensitive to human interaction and touch and sensitivity to energy repatterning 27. spinal manipulation directed at certain joints; a holistic therapy 28. restoring structural and functional imbalances 29. malignancy, bone and joint infections, fractures, dislocations, and arthritis 30. comprises several modalities, herbs, acupuncture, moxibustion, diet, exercise, and meditation 31. a. opposing yet complementary phenomena that exist in a state of dynamic equilibrium b. vital energy of the body c. channels of energy that run in regular patterns through the body and over its surface d. holes through which qi can be influenced by the insertion of needles e. stimulating certain points on the body by the insertion of special needles to modify the perception of pain, normalize physiological functions, or treat and prevent disease 32. low back pain, myofascial pain, headaches, sciatica, shoulder pain, tennis elbow, osteoarthritis, whiplash, and musculoskeletal sprains 33. infections, broken needles, puncture of internal organ, bleeding, fainting, seizures, miscarriage, and post-treatment drowsiness 34. The goal is to restore balance within the individual by facilitating the person’s selfhealing ability. 35. treatment of liver and gallbladder conditions, depression, antivirals 36. contamination with other chemicals or herbs, toxic agents, a variety of standards utilized from one company to another 37. multiple-practitioner treatment group; a pluralistic, complementary health care system; is consistent with the holistic approach nurses learn to practice 38. 2. the perception that the treatments offered by the medical profession do not provide relief for a variety of common illnesses 39. 3. They have not received approval for use a drugs and are not regulated by the FDA; therefore, they can be sold as food or food supplements only. 40. 2. It is important for the nurse to know the current research being done in this area to provide accurate information not only to clients but also to other health care professionals.



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Chapter 37: Activity and Exercise

1. k 2. d 3. p 4. n 5. l 6. m 7. e 8. q 9. o 10. s 11. t 12. f 13. g 14. r 15. b 16. h 17. i 18. j 19. c 20. a 21. The wider the base of support, the greater the stability of the nurse. 22. The lower the center of gravity, the greater the stability. 23. The equilibrium of an object is maintained as long as the line of gravity passes through its base of support. 24. Facing the direction of movement prevents abnormal twisting of the spine. 25. Dividing balanced activity between arms and legs reduces the risk of back injury. 26. Leverage, rolling, turning, or pivoting requires less work than lifting. 27. When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it. 28. a. congenital defects b. disorders of bones, joints, and muscles c. central nervous system damage d. musculoskeletal trauma 29. The infant’s spine is flexed and lacks the anteroposterior curves; as growth and stability increase, thoracic spine straightens, and the lumbar spinal curve appears, which allows for sitting and standing. 30. Posture is awkward due to the slight swayback and protruding abdomen; toward the end of toddlerhood, posture appears less awkward, curves in the cervical and lumbar vertebrae are accentuated, and foot eversion disappears. 31. tremendous growth spurt in girls – hips widen, fat is deposited in upper arms, thighs and buttocks; boys –long bone growth and increased muscle mass 32. Normal changes in posture and alignment occur in pregnant women.



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33. a progressive loss of total bone mass due to physical inactivity, hormonal changes, increased osteoclastic activity 34. the head is erect and midline, body parts are symmetrical, spine is straight with normal curvatures, abdomen is comfortably tucked, kn ees are in a straight line between the hips and ankles and slightly flexed, feet are flat on the floor 35. the head is erect and the neck and vertebral column are in straight alignment, body weight is distributed on the buttocks and thighs, the thighs are parallel and in a horizontal plane, feet are supported on the floor 36. vertebrae are in straight alignment without observable curves; head and neck should be aligned without excessive flexion or extension 37. determine the degree of damage or injury to a joint, joint stiffness, swelling, pain, limited movement, and unequal movement 38. manner or style of walking, including rhythm, cadence, and speed; observing balance, posture, and ability to walk without assistance 39. activity for conditioning the body, improving health, maintaining fitness, or providing therapy for correcting a deformity or restoring the overall body to a maximal state of health 40. See Box 37-7 for answers. 41. a. activity intolerance b. ineffective coping c. impaired gas exchange d. risk for injury e. impaired physical mobility f. imbalanced nutrition g. acute or chronic pain 42. a. participates in prescribed physical activity while maintaining appropriate heart rate, blood pressure, and breathing rate b. verbalizes an understanding of the need to gradually increase activity based on tolerance and symptoms c. expresses understanding of balancing rest and activity 43. subtracting their current age from 220 and then obtain their target heart rate by taking 60% to 90% of the maximum 44. a. walking, running, bicycling, aerobic dance, jumping rope, and cross-country skiing b. active ROM and stretching all muscle groups and joints c. increases muscle strength and endurance; includes weight training, raking leaves, shoveling snow, and kneading bread 45. muscle groups used for walking should be exercised isometrically 4 times per day until the client is ambulatory 46. active –the client is able to move his or her joints independently; passive – the nurse moves each joint 47. increases joint mobility 48.



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a. single straight-legged cane that is used to support and balance a client with decreased leg strength b. quad cane provides more support and is used for partial or complete leg paralysis or some hemiplegia 49. a. each leg is moved alternatively with each opposing crutch so that three points are on the floor at all times b. bears weight on both crutches and then on the uninvolved leg, repeating the sequence c. least partial weight bearing on each foot d. weight is placed on supportive legs; crutches are one stride in front and then swings through with the crutches, supporting the client’s weight 50. reduced mortality and morbidity, improved quality of life, improved left ventricular function, increased functional capacity, decreased blood lipids, and increased psychological well-being 51. reduces systolic and diastolic blood pressure 52. helping clients reach an optimal level of functioning 53. improved cardiovascular fitness and psychological well-being 54. a. pulse b. blood pressure c. strength d. endurance d. psychological well-being 55. 4. definition 56. 2. it increases cardiac output 57. Refer to Figure 37-3 in the text for answers.



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Chapter 38: Client Safety 1. Environment : Includes all of the physical and psychosocial factors that influence the life and the survival of the client. 2. Carbon monoxide : Colorless, odorless, poisonous gas 3. Food poisoning: Staphylococcal and clostridial bacteria are the most common types 4. Food and Drug Administration (FDA): Federal agency responsible for regulating the manufacture, processing, and distribution of foods, drugs, and cosmetics 5. Hypothermia: Core temperature is 35 C or below 6. Relative humidity: Amount of water vapor in the air compared with the maximum amount of water vapor that the air could contain 7. Immunization: Process by which resistance to an infectious disease is produced 8. Air pollution: Contamination of the atmosphere with a harmful chemical 9. Land pollution: Caused by improper disposal of radioactive waste products 10. Water pollution: Contamination of lakes, rivers, and streams by industrial pollutants 11. Noise pollution: Uncomfortable noise level 12. Bioterrorism: The use of anthrax, smallpox, pneumonic plague, and botulism ᵒ

13. In addition to being knowledgeable about the environment, nurses must be familiar with: a. client’s developmental level b. mobility, sensory, and cognitive status c. lifestyle choices d. knowledge of common safety precautions 14. Identify the individual risk factors that can pose a threat to safety : a. lifestyle b. impaired mobility c. sensory or communication impairment d. lack of sensory awareness 15. List the four major risks to client safety in the health care environment a. falls b. client-inherent accidents (seizures, burns, inflicted cuts) c. procedure-related accidents (medication administrations, improper procedures) d. equipment-related accidents (rapid IV infusions, electrical hazards)

Safety and the Nursing Process Assessment 16. Identify the specific client assessments to perform when considering possible threats to the client’s safety . a. nursing history b. client’s home environment c. health care environment



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d. risk for falls e. risk for medical errors Identify the features that should alert nurses to the possibility of a bioterrorism-related out-break. 17. a rapidly increasing incidence of a disease in a normally healthy population 18. an unusual increase in the number of people seeking care with fever, respiratory, or GI symptoms 19. an endemic disease rapidly emerging at an uncharacteristic time, location, or in an unusual pattern 20. lower attack rates among clients are primarily indoors, in areas with filtered or closed ventilation, compared with people who had been outdoors 21. clusters of clients arriving from a single locale 22. large number of rapidly fatal cases 23. any client presenting with a disease that is relatively uncommon to the geographic area and has bioterrorism potential 24. atypical clinical presentation

Nursing Diagnosis Identify actual or potential nursing diagnoses that apply to clients whose safety is threatened. 25. risk for imbalanced body temperature 26. impaired home maintenance 27. risk for injury 28. deficient knowledge 29. risk for poisoning 30. disturbed sensory/perception 31. risk for suffocation 32. disturbed thought processes 33. risk for trauma

Planning 34. Identify the expected outcomes that focus on the client’s need for safety . a. modifiable hazards will be reduced in the home environment by 100% within 1 month b. client does not suffer a fall or injury c. client identifies risks associated with visual impairment

Implementation Health promotion 35. Identify general preventive measures to ensure a safer environment . Meet the basic needs related to oxygen, nutrition, temperature, and humidity



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Acute Care 36. List eight measures to prevent falls in the health care setting a. Place disoriented clients in room near nurses’ station. b. Maintain close supervision of confused clients. c. Show the client how to use the call light at the bedside and in bathroom, and place within easy reach. d. Place bedside tables and over-bed tables close to client. e. Remove clutter from bedside tables, hallways, bathrooms, and grooming areas. f. Leave one side rail up and one down on the side where the oriented and ambulatory client gets out of bed. g. Lock beds and wheelchairs when transferring a client from a bed to a wheelchair or back to bed. h. Place side rails in the up position, and secure safety straps around the client on a stretcher. 37. A physical restraint is : is a human, mechanical, and/or physical device that is used with or without the client’s permission to restrict his/her freedom of movement or normal access to a person’s body and is not a usual part of the treatment plan 38. Use of restraints must meet the following objectives a. reduce the risk of client injury from falls b. prevent interruption of therapy c. prevent the confused or combative client from removing life support equipment d. reduce the risk of injury to others by the client 39. Explain why an ambularm is used : a device that signals when the leg is in a dependent position 40. Explain the mnemonic RACE to set priorities in case of fire: R – rescue and remove all clients in immediate danger A – activate the alarm C –confine the fire by closing doors and windows and turning off oxygen and electrical equipment E – extinguish the fire using an extinguisher 41. A poison is: is any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body 42. Explain seizure precautions to take: are nursing interventions to protect clients from traumatic injury, positioning for adequate ventilation and drainage or oral secretions, and providing privacy and support following the event



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43. Identify the measures with which the nurse must be familiar to reduce exposure to radiation : limit the time spent near the source, make the distance from the source as great as possible, and use shielding devices 44. process to determine hazard vulnerability for the hospital’s service area 45. steps taken to increase a hospital’s ability to manage effects of an attack 46. steps taken by the staff in the event of an attack 47. steps taken to restore essential services and resume normal agency operations 48. 3. physiological needs , including the need for oxygen, nutrition, and optimum temperature and humidity; influence a person’s safety 49. 4. due to the physiological changes that occur during the aging process, increase the client’s risk for falls 50. 3. Use the RACE to set priorities in case of fire. 51. 4. The related factor becomes the basis for the selection of nursing therapies. 52. a. Ms. Cohen states, “I bump into things , and I’m afraid I’m going to fall .” Cabinets in kitchen are disorganized and full of breakable items that could fall out. Throw rugs are on floors ; bathroom lighting is poor (40-watt bulbs ); bathtub lacks safety strips or grab bars ; home cluttered with furniture and small objects. Ms. Cohen has kyphosis and has a hesitant, uncoordinated gait . She frequently holds walls for support. Ms. Cohen’s left arm and leg are weaker than those on the right. Ms. Cohen has trouble reading and seeing familiar objects at a distance while wearing current glasses. b. In the case of safety, the nurse integrates knowledge from nursing and other scientific disciplines and previous experiences in caring for clients who had an injury or were at risk. c. The American Nurses Association (ANA) standards for nursing practice address the nurse’s responsibility in maintaining client safety. d. Critical-thinking attitudes such as perseverance and creativity would be applicable in this case.



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Chapter 39: Hygiene

1. a. outer layer b. thicker layer containing bundles of collagen and elastic fibers c. contains blood vessels, nerves, lymph, and loose connective tissue with fat cells 2. a. protection b. sensation c. temperature regulation d. excretion and secretion 3. a. fold of skin at the nail groove b. crescent-shaped white area 4. a. found in the mucosa lining the cheeks and mouth, which maintain the hygiene and comfort of oral tissues b. chewing c. gum inflammation 5. a. social practices b. personal preferences c. body image d. socioeconomic status e. health beliefs and motivation f. cultural variables g. physical condition 6. the color, texture, thickness, turgor, temperature, and hydration 7. a. Dry skin: Bathe less frequently and rinse body of all soap because residue left on skin can cause irritation and breakdown. Add moisture to air through use of humidifier. Increase fluid intake when skin is dry. Use moisturizing cream to aid healing. (Cream forms protective barrier and helps maintain fluid within skin.) Use cream such as Eucerin. Use creams to clean skin that is dry or allergic to soaps and detergents. b. Acne: Wash hair and skin thoroughly each day with warm water and soap to remove oil. Use cosmetics sparingly because oily cosmetics or creams accumulate in pores and tend to make condition worse. Implement dietary restrictions, if necessary. (Eliminate foods that aggravate condition from diet.) Use prescribed topical antibiotics for severe forms of acne. c. Skin rashes: Wash area thoroughly and apply antiseptic spray or lotion to prevent further itching and aid in healing process. Apply warm or cold soaks to relieve inflammation, if indicated. d. Contact dermatitis: Avoid causative agents (e.g., cleansers and soaps). e. Abrasion: Be careful not to scratch client with jewelry or fingernails. Wash abrasions with mild soap and water; dry thoroughly and gently. Observe dressing or bandage for retained moisture because it increases risk of infection. 8. a. Immobilization: When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. Know which clients require assistance to turn and change positions. b. Reduced sensation: Clients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. During a bath, assess the status of sensory nerve function by checking for pain, tactile sensation, and temperature sensation. c. Nutrition and hydration: Clients with limited caloric and protein intake develop thinner, less elastic skin, with loss of subcutaneous tissue. This results in impaired or delayed wound healing.



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d. Secretions and excretions: Moisture on the skin’s surface serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. Presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in breakdown and infection. e. Vascular insufficiency: Inadequate arterial supply to tissues and impaired venous return decrease circulation to the extremities. Inadequate blood flow causes ischemia and breakdown. Risk of infection also exists because delivery of nutrients, oxygen, and white blood cells to injured tissues is inadequate. f. External devices: An external device applied to or around the skin exerts pressure or friction on the skin. Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. 9. a. Calluses: Thickened portion of epidermis consists of mass of horny, keratotic cells. Callus is usually flat, painless, and found on undersurface of foot or on palm of hand. b. Corns: Friction and pressure from ill-fitting or loose shoes cause keratosis. Corns are seen mainly on or between toes, over bony prominences. Corns are usually coneshaped, round, and raised. Soft corns are macerated. c.

Plantar warts: Fungating lesion appears on sole of foot and is caused by the papilloma virus.

d. Tinea pedis: Athlete’s foot is fungal infection of foot; scaliness and cracking of skin occurs between toes and on soles of feet. Small blisters containing fluid appear. e.

Ingrown nails: Toenail or fingernail grows inward into soft tissue around nail. Ingrown nail often results from improper nail trimming.

f.

Foot odors: Foot odors are the result of excess perspiration promoting microorganism growth. 10. bad breath 11. a. Dandruff: Scaling of scalp is accompanied by itching. In severe cases, dandruff is on eyebrows. b. Ticks: Small, gray-brown parasites burrow into skin and suck blood. c. Pediculosis: Tiny, grayish-white parasite insects infest mammals. d. Pediculosis capitis: Parasite is on scalp attached to hair strands. Eggs look like oval particles, similar to dandruff. Bites or pustules may be observed behind ears and at hairline. e. Pediculosis corporis: Parasites tend to cling to clothing, so they are not always easy to see. Body lice suck blood and lay eggs on clothing and furniture. f. Pediculosis pubis: Parasites are in pubic hair. Crab lice are grayish white with red legs. g. Alopecia: Alopecia occurs in all races. Balding patches are in periphery of hair line. Hair becomes brittle and broken.



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12. a. Oral problems: Clients who are unable to use upper extremities due to paralysis, weakness, or restriction (e.g., cast or dressing); Dehydration, inability to take fluids or food by mouth (NPO); Presence of nasogastric or oxygen tubes; mouth breathers; Chemotherapeutic drugs; Lozenges, cough drops, antacids, and chewable vitamins over-the-counter (OTC); Radiation therapy to head and neck; Oral surgery, trauma to mouth, placement of oral airway; Immunosuppression; altered blood clotting; Diabetes mellitus b. Skin problems: Immobilization; Reduced sensation due to stroke, spinal cord injury, diabetes, local nerve damage; Limited protein or caloric intake and reduced hydration (e.g., fever, burns, gastrointestinal alterations, poorly fitting dentures); Excessive secretions or excretions on the skin from perspiration, urine, watery fecal material, and wound drainage; Presence of external devices (e.g., casts, restraints, bandage, dressing); Vascular insufficiency c. Foot problems: Client unable to bend over or has reduced visual acuity d. Eye care problems: Reduced dexterity and hand coordination 13. chronic low self-esteem 14. deficient knowledge about hygiene practices 15. fatigue 16. impaired dentition 17. impaired oral mucous membrane 18. impaired physical mobility 19. ineffective health maintenance 20. ineffective tissue perfusion 21. risk for impaired skin integrity 22. risk for infection 23. a. client’s skin is clean, dry, and intact without signs of inflammation b. skin remains elastic and well-hydrated c. range of joint motion remains within normal limits on both affected and unaffected side 24. a. make all instructions relevant after assessing knowledge, motivations, and health beliefs b. adapt instruction of any techniques to the client’s personal bathing facilities c. teach the client steps to avoid injury d. reinforce infection-control practices 25. a. complete bed bath: Bath administered to totally dependent client in bed (Skill 39-1) b. partial bed bath: Bed bath that consists of bathing only body parts that would cause discomfort if left unbathed, such as the hands, face, axillae, and perineal area. Partial bath also includes washing back and providing back rub. Dependent clients in need of partial hygiene or self-sufficient bedridden clients who are unable to reach all body parts receive a partial bath. c. sponge bath: Involves bathing from a bath basin or sink with the client sitting in a chair. Client is able to perform a portion of the bath independently. Assistance is needed for hard-to- reach areas. d. tub bath: Involves immersion in a tub of water that allows more thorough washing and rinsing than a bed bath. Client may still require the nurse’s assistance. Some institutions have tubs equipped with lifting devices that facilitate positioning dependent clients in the tub.



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e. bed bath/travel bath: Developed by Skewes (1994), the Bag Bath contains several soft, nonwoven cotton cloths that are premoisted in a solution of no-rinse surfactant cleanser and emollient. The Bed Bath offers an alternative because of the ease of use, reduced bathing time, and client comfort. 26. a. provide privacy b. maintain safety c. maintain warmth d. promote independence e. anticipate needs 27. greatest risk are those males who are uncircumcised, clients who have indwelling catheters, or clients recovering from rectal or genital surgery or childbirth 28. promotes relaxation, relieves muscular tension, and decreases perception of pain 29. Inspect the feet daily, using a mirror. 30. Instruct client to wash feet daily in lukewarm water and dry thoroughly. 31. foot examination yearly 32. unscented foot powder for perspiration 33. clean, dry socks 34. apply lanolin, baby oil to dry areas of feet 35. file the toenails straight across and square 36. do not use OTCs to treat foot conditions; consult with physician 37. Avoid wearing elastic stockings. 38. Wear properly fitted shoes. 39. Do not wear new shoes for an extended time. 40. Exercise regularly to improve circulation. 41. Wash minor cuts immediately and dry thoroughly. 42. Thorough tooth brushing at least 4 times a day is basic; obtain new brushes every 3 months. 43. removes plaque and tartar between teeth 44. need to be cleaned on a regular basis to avoid gingival infection and irritation 45. helps to keep hair clean and distributes oil evenly along hair shafts; prevents hair from tangling 46. frequency depends on a person’s daily routines and the condition of the hair 47. Shave facial hair after the bath or shampoo; to avoid causing discomfort, gently pull the skin taut and use short, firm razor strokes in the direction the hair grows. 48. They require daily grooming due to food particles and mucus that collect on the hair. 49. Unconscious clients will require more frequent eye care; wash with a clean washcloth moistened in water. 50. daily wear, extended wear, and disposable 51. a. use a small, rubber bulb syringe to create a suction effect; place directly over the eye; squeezing lifts the eye from the socket b. warm normal saline c. retract the upper and lower lids and gently slip the eye into the socket d. in a labeled container filled with tap water or saline 52. Instill 3 drops of glycerin at bedtime to soften the wax and 3 drops of hydrogen peroxide twice a day to loosen the wax; then instill 250 cc of warm water into the ear, which will wash away the loosened wax. 53. a. it requires adequate ear diameter and depth for proper fit; it does not accommodate progressive hearing loss and requires manual dexterity to operate b. fits into the external ear and allows for more fine tuning, powerful, easy to adjust c. hooks around



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and behind the ear and is connected to an ear mold, allows for fine tuning, useful for clients with progressive hearing loss 54. a. Fowler’s: Head of bed raised to angle of 45 degrees or more; semi-sitting position; foot of bed may also be raised at knee b. Semi-Fowler’s: Head of bed raised approximately 30 degrees; inclination less than Fowler’s position; foot of bed may also be raised at kne e c. Trendelenburg’s: Entire bed frame tilted with head of bed down d. Reverse Trendlenburg’s: Entire bed frame tilted with foot of bed down e. Flat: Entire bed frame horizontally parallel with floor 55. 2. a bath that is administered to totally dependent client in bed 56. 2. The condition of the skin depends on the exposure to environmental irritants; with frequent bathing or exposure to low humidity, the skin becomes very dry and flaky. 57. 3. Each client has individual desires and preferences about when to bathe, shave, and perform hair care. 58. 2. File the toenails straight across and square; do not use scissors or clippers; consult a podiatrist as needed. 59. 3. Use a medicated shampoo for eliminating lice, which is easily able to spread to furniture and other people if not treated. 60. Mrs. Edith Wyatt is a 77-year-old female with a history of degenerative arthritis and diabetes mellitus for 3 years and complains of pain in the joints, weakness, and mobility limitations in the dominant hand. Mrs. Wyatt is a widow with her only child, a daughter, living in a city 200 miles away. Mrs. Wyatt lives in a first-floor apartment in a retirement center. She moved in three weeks earlier. The nurse, Jeannette, makes the initial home visit for Mrs. Wyatt. Jeannette’s assessment reveals defining characteristics of an inability to wash body parts, unkempt appearance, difficulty turning and regulating a water faucet, and limited motion of arms. Jeannette also observes Mrs. Wyatt to have a right limp. Her shoes are worn and illfitting. Jeannette synthesizes information that she has obtained from her assessment to develop a plan of care. She involves Mrs. Wyatt in the plan by asking her what is important to her to gain from her visit. She wants to continue to be independent in making decisions about her care. She tells Jeannette, “It is important for me to be able to care for myself.” Jeannette assesses the client’s tolerance for activity, discomfort level, cognitive ability, and musculoskeletal function, which determines client’s ability to perform self-care and level of assistance required from nurse. Assess range of motion of upper ex tremities. She states, “it hurts to move my arms above my head.” Jeannette also assesses the client’s bathing preferences: frequency and time of day, type of hygiene products. Mrs. Wyatt states, “I cannot get used to the new bathroom. The floor in the shower is slippery. I cannot reach my towels and soap. I have not been to the hair dresser since I arrived here.” Mrs. Wyatt’s hair is not washed or combed. Current bathroom has a shower with handgrips; levers turn up and down versus clockwise, and shower seat is available. The handles on the shower are levers versus faucets. The room also has a small closet for linens with a large counter top adjunct to sink. Jeannette asked



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Mrs. Wyatt how long she has limped and if she has any pain. Mrs. Wyatt replies “My right foot hurts, especially by the little toe. This has been going on for about two weeks.” Jeannette assesses the condition of Mrs. Wyatt’s feet and her knowledge about prevention and routine foot care. Both feet are dry and toenails evenly trimmed at end of toe. The outer aspect of the little toe on right foot is reddened, tender to touch with intact skin. Mrs. Wyatt states, “I have my doctor trim my toenails every month, because of my sugar problems.” Jeannette involved Mrs. Wyatt when making decisions regarding her care. She became creative in adapting an approach to her self-care by setting up an appointment with a home health-care agency to provide a home-care assistant to assist Mrs. Wyatt with her bathing and hair care. Mrs. Wyatt states that she has a monthly appointment scheduled for the next 6 months for toenail trimming and care.



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Chapter 40: Oxygenation

1. c 2. e 3. h 4. f 5. b 6. g 7. a 8. d 9. conduction thru both atria 10. impulse travel time through the AV node (.012 -.20 seconds) 11. the impulse traveled through the ventricles (0.06 – 0.12 seconds) 12. time needed for ventricular depolarization and repolarization (0.12-0.42 seconds) 13. e 14. g 15. i 16. j 17. h 18. d 19. f 20. b 21. a 22. c 23. a. cardiac disorders: disturbances in conduction, impaired valvular function, myocardial hypoxia, cardiomyopathic conditions, and peripheral tissue hypoxia Respiratory disorders (hyperventilation, hypoventilation, hypoxia) b. alterations that affect the oxygen-carrying capacity (anemia) c. decreased inspired oxygen concentration (high altitudes, drug overdoses) d. hypovolemia (shock and severe dehydration) e. increased metabolic rate (pregnancy, fever, infection) 24. a. pregnancy (inspiratory capacity declines) b. obesity (reduced lung volumes) c. musculoskeletal abnormalities (structural configurations, trauma, muscular disease, CNS) d. trauma (flail chest, incisions) e. neuromuscular diseases (decrease the ability to expand and contract the chest wall) f. CNS (reduced inspiratory lung volumes) g. chronic diseases (chronic hypoxemia) 25. a. Regular rhythm, rate greater than 100 b. Regular rhythm, rate less than 60 c. Electrical impulse in the atria is chaotic and originates from multiple sites



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d. Life threatening, impulse originates in ventricles, QRS complex is usually widened and bizarre e. Uncoordinated electrical activity, no identifiable P, QRS, or T wave 26. a. decreased functioning of the left ventricle (fatigue, breathlessness, dizziness, and confusion) b. impaired functioning on the right ventricle (weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema) 27. a. flow of blood through the valve is obstructed b. back flow of blood into an adjacent chamber 28. results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet the myocardial oxygen demand 29. transient imbalance between myocardial oxygen supply and demand 30. results from a sudden decrease in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion 31. includes unstable angina, non-ST segment elevation MI, and ST-segment elevation, MI (nonocclusive thrombus, coronary vasospasm, atherosclerosis, inflammation, or infection) 32. excess ventilation required to eliminate the carbon dioxide produced (anxiety, infections, drugs, or an acid-base imbalance) 33. alveolar ventilation is inadequate to meet the body’s oxygen demand 34. collapse of the alveoli which prevents normal exchange of oxygen and carbon dioxide 35. inadequate tissue oxygenation at the cellular level (decreased hemoglobin levels, high altitudes, poisoning, pneumonia, shock, chest trauma) 36. blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries 37. upper respiratory tract infections due to frequent exposures and secondhand smoke 38. exposure to respiratory infections, secondhand smoke, and smoking 39. unhealthy diet, lack of exercise, stress, OTCs, illegal substances, smoking 40. aging changes, osteoporosis 41. a. smoking cessation b. weight reduction c. low-cholesterol and low-sodium diet d. management of hypertension e. moderate exercise 42. a. asbestos b. talcum powder c. dust d. airborne fibers 43. a. cardiac function – pain, dyspnea, fatigue, peripheral circulation, cardiac risk factors b. respiratory function – cough, SOB, wheezing, pain, environmental exposure, frequency of infections, risk factors, medication use, smoking use



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44. a. does not occur with respiratory variations b. is peripheral and radiates to the scapular regions c. often present following exercise, trauma, prolonged coughing episodes 45. is a subjective sensation (loss of endurance) 46. clinical sign of hypoxia, usually associated with exercise or excitement associated with many medical and environmental factors 47. abnormal condition in which the client uses multiple pillows when lying down 48. sudden, audible expulsion of air from the lungs; a protective reflex to clear the trachea, bronchi, and lungs of irritants and secretions 49. high-pitched musical sound caused by high-velocity movement of air through a narrowed airway 50. observe the client for skin and mucous membrane color, general appearance, level of consciousness, systemic circulation, breathing patterns, and chest wall movement 51. type of thoracic excursion; areas of tenderness; identifies tactile fremitus, thrills, heaves, and PMI 52. detects the presence of abnormal fluid or air in the lungs 53. identify normal and abnormal heart and lung sounds 54. a. Holter monitor: Portable ECG worn by the client. The test produces a continuous ECG tracing over a period of time. Clients keep a diary of activity, noting when they experience rapid heartbeats or dizziness. Evaluation of the ECG recording along with the diary provides information about the heart’s electrical activity during activities of daily living. b. Exercise stress test: ECG is monitored while the client walks on a treadmill at a specified speed and duration of time. Used to evaluate the cardiac response to physical stress. The test is not a valuable tool for eva luation of cardiac response in women due to an increased false-positive finding. c. Thallium stress test: An ECG stress test with the addition of thallium-201 injected IV. Determines coronary blood flow changes with increased activity. d. Electrophysiological studies (EPS): Invasive measure of intracardiac electrical pathways. Provides more specific information abo ut difficult-to-treat dysrhythmias. Assesses adequacy of antidysrhythmic medication. e. Echocardiography: Noninvasive measure of heart structure and heart wall motion. Graphically demonstrates overall cardiac performance. f. Scintigraphy: Radionuclide angiography. Used to evaluate cardiac structure, myocardial perfusion, and contractility. g. Cardiac catheterization and angiography: Used to visualize cardiac chambers, valves, the great vessels, and coronary arteries. Pressures and volumes within the four chambers of the heart are also measured. 55. a. Pulmonary function tests: Determine the ability of the lungs to efficiently exchange oxygen and carbon dioxide. Used to differentiate pulmonary obstructive disease from restrictive disease.



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b. Peak expiratory flow rate (PEFR): The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. Daily measurement is for early detection of asthma exacerbations. c. Bronchoscopy: Visual examination of the tracheobronchial tree through a narrow, flexible fiberoptic bronchoscope. Performed to obtain fluid, sputum, or biopsy samples; remove mucous plugs or foreign bodies. d. Lung scan: Used to identify abnormal masses by size and location. Identification of masses is used in planning therapy and treatments. e. Thoracentesis: Specimen of pleural fluid is obtained for cytological examination. The results may indicate an infection or neoplastic disease. Identification of infection or a type of cancer is important in determining a plan of care. 56. activity intolerance 57. anxiety 58. decreased cardiac output 59. fatigue 60. impaired gas exchange 61. impaired spontaneous ventilation 62. impaired verbal communication 63. ineffective airway clearance 64. ineffective breathing pattern 65. ineffective health maintenance 66. risk for imbalanced fluid volume 67. risk for infection 68. a. lungs are clear to auscultation b. achieves maintenance and promotion of bilateral lung expansion c. coughs productively d. pulse oximetry is maintained or improved 69. a. exercise b. breathing techniques c. cough control d. relaxation techniques e. biofeedback f. meditation 70. a. humidification b. nebulization c. chest physiotherapy d. postural drainage 71. a. oropharyngeal and nasopharyngeal b. orotracheal and nasotracheal c. artificial airway 72. frequent changes of position are effective for reducing stasis of pulmonary secretions and decreased chest wall expansion (Semi-Fowler’s is the most effective position)



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73. encourages voluntary deep breathing and prevents atelectasis by using visual feedback 74. a. to remove air and fluids from the pleural space b. to prevent air or fluid from reentering the pleural space c. to reestablish normal intrapleural and intrapulmonic pressures 75. a. accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae usually due to trauma b. collection of air in the pleural space, caused by loss of negative intrapleural pressure 76. is to prevent or relieve hypoxia 77. a. Nasal cannula: A nasal cannula is a simple, comfortable device used for oxygen delivery (Skill 40-4). The two cannulas, about 1.5 cm (½ inch) long, protrude from the center of a disposable tube and are inserted into the nares (Figure 40-13). Advantages include: safe and simple; easily tolerated; delivers low concentrations while allowing the client to eat, speak, and drink; does not impede eating or talking; is inexpensive and disposable. Disadvantages include: unable to use with nasal obstruction; drying to mucous membranes; can dislodge easily; causes skin irritation or breakdown; client’s breathing pattern will affect exact FIO2. b. Face mask: An oxygen face mask is a device used to administer oxygen, humidity, or heated humidity. It fits snugly over the mouth and nose and is secured in place with a strap and it assists in providing humidified oxygen. Disadvantages include: exact FIO2 level is difficult to estimate; requires high FIO2 levels to prevent re-breathing of carbon dioxide; client inhales room air through the side holes in the mask. c. Venturi mask: The Venturi mask delivers oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min, depending on the flow-control meter selected. Advantages include: controls the amount of specified oxygen concentration. Delivers percentage of FIO2 from 24-60%; does not dry mucous membranes; delivers humidity with oxygen concentration. 78. a PaO2 of 55 mm Hg or less or an SaO 2 of 88% or less on room air at rest, on exertion, or with exercise 79. A-airway B-breathing C-circulation 80. a. physical exercise b. nutrition counseling c. relaxation and stress management techniques d. prescribed medications and oxygen e. compliance 81. cascade cough – promotes airway clearance and patent airway in clients with large volumes of sputum. Huff cough – stimulates a natural cough reflex and is effective only for clearing central airways 82. improves muscle strength and endurance 83. involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse



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84. improves efficiency of breathing by decreasing air trapping and reducing the work of breathing 85. a. evaluation of ABGs b. PFTs c. VS d. ECG e. physical assessment data 86. 1. These are the 3 steps in the process of oxygenation. 87. 1. The heart must work to overcome this resistance to fully eject blood from the left ventricle. 88. 2. Gases move into and out of the lungs through pressure changes (intrapleural and atmospheric). 89. 3. All other answers are related to the subjective sensation of dyspnea. 90. 2. CPT includes postural drainage, percussion, and vibration. 91. Mr. Edwards’ statement indicates that he has a co ugh, does not exercise, is fatigued, and continues to smoke ½ pack of cigarettes a day. Mr. Edwards’ skin and mucus membranes are dry; he has abnormal breath sounds in the lower lobes and has a productive cough of thick and discolored yellow-to-yellow green sputum. His SpO2 ranges from 78-84%, and his vital signs are 100.4, 130/90, 88, 26 SpO2 87%. Interventions based upon the data would include increasing fluids to 1000 mL in 24 hours to liquefy secretions, have Mr. Edwards deep breathe and cough every 2 hours 4 to 5 times, and teach Mr. Edwards effective cough techniques to clear secretions. Initiate chest physiotherapy (CPT) if there is evidence of infiltrates on chest X-ray. Help identify community resources and support systems for both the client and family in preventing and managing symptoms related to his COPD upon discharge from the hospital.



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Chapter 41: Fluid, Electrolyte, and Acid-Base Balance

1. a. comprises all fluid within the cells of the body (42% of body weight) b. is the fluid outside the cell (interstitial, intravascular, and transcellular fluid) 2. positively charged electrolytes (sodium, potassium, and calcium) 3. negatively charged electrolytes (chloride, bicarbonate, and sulfate) 4. represents the number of grams of the specific electrolyte dissolved in a liter of plasma 5. are electrolytes, oxygen, carbon dioxide, glucose, and proteins 6. involves the movement of a pure solvent across a semipermeable membrane from an area of lesser solute concentration to an area of greater solute concentration 7. The concentration of a solution is measured, which reflects the amount of a substance in the form of molecules, ions, or both. 8. is the drawing power of water and depends on the number of molecules in solution 9. the osmotic pressure of a solution 10. another term that describes the concentration of solution 11. the solutions on both sides of the semipermeable membrane are equal in concentration (expand the body’s fluid volume without causing a fluid shift from one compartment to another) 12. a solution of higher osmotic pressure (pulls fluid from cells, causing them to shrink) 13. a solution of lower osmotic pressure (moves fluids into the cells, causing them to enlarge) 14. random movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration 15. the difference between 2 concentrations 16. is the process by which water and diffusible substances move together across a membrane, in response to fluid pressure, moving from an area of higher pressure to one of lower pressure 17. requires metabolic activity and expenditure of energy to move substances across the cell membrane 18. a. fluid intake b. hormonal controls c. fluid output 19. continually monitor the serum osmotic pressure 20. excess fluid is lost 21. at risk are clients who are unable to perceive or respond to the thirst mechanism 22. ADH – is stored in the pituitary gland and is released in response to changes in the blood osmolarity 23. a. causes vasoconstriction b. massive selective vasoconstriction of blood vessels; relocates blood flow to kidneys and stimulates the release o f aldosterone (when the sodium is low) c. adrenal cortex releases in response to increased plasma potassium levels 24. plays a critical role in the balance of fluid and electrolytes and the maintenance of vascular tone 25. kidneys, skin, lungs, gastrointestinal tract 26. a. is continuous and occurs through the skin and lungs; not perceived by the person b. occurs through excess perspiration and can be perceived by the client 27.



Electrolyte Sodium

Values 135-145 mEq/L

Potassium

3.5-5.0 mEq/L

Calcium

4.5-5.5 mg/dl

Magnesium

1.5-2.5 mEq/L

Chloride

95-105 mEq/L

Bicarbonate

22-26 (arterial) mEq/L 24-30 (venous) mEq/L

Phosphate

2.8-4.5 mg/dl

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Function Regulatory Mechanism Major contributor to maintaining Dietary intake and water balance aldosterone secretion Is necessary for glycogen Dietary intake and renal deposits in the liver and skeletal excretion regulate muscle, transmission and potassium. conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction Bone and teeth formation, blood Absorbed from intestine, clotting, hormone secretion, cell excreted by the kidneys membrane integrity, cardiac and resorption or conduction, transmission of deposition in bone. nerve impulses, and muscle Regulated by parathyroid contraction hormone, vitamin D & calcitonin. Essential for enzyme activities, Serum magnesium is neurochemical activities, and regulated by dietary cardiac and skeletal muscle intake, renal excitability mechanisms, and actions of the parathyroid hormone (PTH). Chloride is the major anion in Serum chloride is ECF. The transport of chloride regulated by dietary follows sodium. intake and the kidneys. The bicarbonate ion is an The kidneys regulate essential component of the bicarbonate. carbonic acid-bicarbonate buffering system essential to acid-base balance. It assists in acid-base regulation. Phosphate is normally Phosphate and calcium help to absorbed through the GI develop and maintain bones and tract. It is regulated by teeth. Phosphate also promotes dietary intake, renal normal neuromuscular action and excretion, intestinal participates in carbohydrate absorption, and PTH. metabolism.

28. a. chemical b. biological c. physiological buffering



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29. Imbalance Hyponatremia

Lab Finding serum sodium level below 135 mEq/L, serum osmolality 280 mOsm/kg, and urine specific gravity below 1.010 (if not caused by SIADH)

Hypernatremia

serum sodium levels above 145 mEq/L, serum osmolality 300 mOsm/kg, and urine specific gravity 1.030 (if not caused by diabetes insipidus)

Hypokalemia

serum potassium level below 3.5 mEq/L and electrocardiogram (ECG) abnormalities: flattened T wave; ST segment depression; u wave; potentiated digoxin effects (e.g., ventricular dysrhythmias) serum potassium level above 5.0 mEq/L and ECG abnormalities: peaked T wave and widened QRS complex (bradycardia, heart block, dysrhythmias); eventually QRS pattern widens, and cardiac arrest occurs serum ionized calcium level below 4.5 mEq/L or total serum calcium below 8.5 mg/dl and ECG abnormalities: ventricular tachycardia

Hyperkalemia

Hypocalcemia

Signs and Symptoms apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions, and coma extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability weakness and fatigue; muscle weakness; nausea and vomiting; intestinal distention; decreased bowel sounds; decreased deep tendon reflexes; ventricular dysrhythmias; paresthesias; and weak, irregular pulse

anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea

numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, positive Trousseau’s sign (carpopedal spasm with hypoxia), positive Chvostek’s sign (contraction of facial muscles when facial



Hypercalcemia

Hypomagnesemia

Hypermagnesemia

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serum ionized calcium level above 5.5 mEq/L or total serum calcium level above 10.5 mg/dl; x-ray examination showing generalized osteoporosis, widespread bone cavitation, radiopaque urinary stones; and elevated blood urea nitrogen (BUN) level 25 mg/100 ml and elevated creatinine level 1.5 mg/100 ml caused by fluid volume deficit (FVD) or renal damage caused by urolithiasis; ECG abnormalities: heart block serum magnesium level below 1.5 mEq/L

serum magnesium level above 2.5 mEq/L; ECG abnormalities: prolonged QT interval, AV block

nerve is tapped), tetany, muscle cramps, and pathological fractures (chronic hypocalcemia) anorexia, nausea and vomiting, weakness, hypoactive reflexes, lethargy, flank pain (from kidney stones), decreased level of consciousness, personality changes, and cardiac arrest

muscular tremors, hyperactive deep tendon reflexes, confusion and disorientation, tachycardia, hypertension, dysrhythmias, and positive Chvostek’s sign and Trousseau’s sign acute elevations in magnesium levels: hypoactive deep tendon reflexes, decreased depth and rate of respirations, hypotension, and flushing

30. a. measures the hydrogen ion concentration in the body fluids (7.35-7.45) b. is the partial pressure carbon dioxide in arterial blood (35-45) c. is the partial pressure of oxygen in the blood (80-100) d. is the point at which hemoglobin is saturated by oxygen (95-99% ) e. is the amount of blood buffer (hemoglobin and bicarbonate) that exists (+/- 2) f. is the major renal component of acid-base balance (22-26)



31. Acid-Base Imbalance Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

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Lab Findings arterial blood gas alterations: pH < 7.35, PaCO2 > 45 mm Hg, PaO2 < 80 mm Hg, and bicarbonate level normal (if uncompensated) or > 26 mEq/L (if compensated) arterial blood gas alterations: pH > 7.45, PaCO2 < 35 mm Hg, PaO2 normal, and bicarbonate level normal (if short lived or uncompensated) or < 22 mEq/L (if compensated) arterial blood gas alterations: pH < 7.35, PaCO2 normal (if uncompensated) or < 35 mm Hg (if compensated), PaO2 normal or increased (with rapid, deep respirations), bicarbonate level < 22 mEq/L, and oxygen saturation normal arterial blood gas alterations: pH > 7.45, PaCO2 normal (if uncompensated) or > 45 mm Hg (if compensated), PaO2 normal, and bicarbonate level > 26 mEq/L

Signs and Symptoms confusion, dizziness, lethargy, headache, ventricular dysrhythmias, warm and flushed skin, muscular twitching, convulsions, and coma dizziness, confusion, dysrhythmias, tachypnea, numbness and tingling of extremities, convulsions, and coma

headache, lethargy, confusion, dysrhythmias, tachypnea with deep respirations, abdominal cramps, and flushed skin

Dizziness; dysrhythmias; numbness and tingling of fingers, toes, and circumoral region; muscle cramps; tetany

32. a. b. c. d.

Age – Very young; very old Gender – Women Environment – Diet, exercise, and hot weather and sweating Chronic Diseases – Cancer; cardiovascular disease, such as congestive heart failure; endocrine diseases such as Cushing’s disease and diabetes mellitus; malnutrition; chronic obstructive pulmonary disease; and renal disease e. Trauma – Crash injuries; head injuries; burns f. Therapies – Diuretics, steroids, intravenous (IV) therapy, and total parenteral nutrition (TPN) 33. Infants and children have greater water needs and are more vulnerable to fluid volume alterations; fever in children creates an increase in the rate of insensible water loss; adolescents have increased metabolic processes; older adults have decreased thirst sensation that often causes electrolyte imbalances.



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34. Surgery, head and chest trauma, shock, and second- and third-degree burns place the clients at risk. 35. The more extensive the surgery and fluid loss, the greater the body’s response. 36. The greater the body surface burned, the greater the fluid loss. 37. predispose to respiratory acidosis and/or respiratory alkalosis 38. can result in cerebral edema and diabetes insipidus 39. cancer, CHF, or renal disease 40. depends on the type and progression of the cancer and its treatment (diarrhea and anorexia) 41. diminished cardiac output, which reduces kidney perfusion and decreases urine output 42. causes an abnormal retention of sodium chloride, potassium and water (metabolic acidosis) 43. gastroenteritis and nasogastric suctioning result in the loss of fluid, potassium, and chloride ions 44. vigorous exercise or exposure to extreme temperatures 45. recent changes in appetite or the ability to chew and swallow (breakdown of glycogen and fat stores, metabolic acidosis, hypoalbuminemia, edema) 46. history of smoking or alcohol consumption (respiratory acidosis) 47. Diuretics —metabolic alkalosis, hyperkalemia, and hypokalemia Steroids —metabolic alkalosis Potassium supplements— GI disturbances, including intestinal and gastric ulcers and diarrhea Respiratory center depressants(e.g., opioid analgesics)— decreased rate and depth of respirations, resulting in respiratory acidosis Antibiotics —nephrotoxicity (e.g., vancomycin, methicillin, aminoglycosides); hyperkalemia and/or hypernatremia (e.g., azlocillin, carbenicillin, piperacillin, ticarcillin, unasyn) Calcium carbonate (Tums) — mild metabolic alkalosis with nausea and vo miting Magnesium hydroxide (Milk of Magnesia)— hypokalemia Nonsteroidal anti-inflammatory drugs— nephrotoxicity 48. a. Weight loss of 5% to 8%: Mild-to-moderate fluid volume deficit (FVD) b. Irritability: Metabolic or respiratory alkalosis, hyperosmolar imbalance, hypernatremia, hypokalemia c. Lethargy: FVD, metabolic acidosis or alkalosis, respiratory acidosis, hypercalcemia d. Periorbital edema: FVE e. Sticky, dry mucous membranes: FVD, hypernatremia f. Chvostek’s sign: hypocalcemia g. Distended neck veins: FVE h. Dysrhythmias: Metabolic acidosis, respiratory alkalosis and acidosis, potassium imbalance, hypomagnesemia i. Weak pulse: FVD, hypokalemia j. Low blood pressure: FVD, hyponatremia, hyperkalemia, hypermagnesemia


Study Guide Answer Key k. l.

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Third heart sound: FVE Increased respiratory rate: FVE, respiratory alkalosis, metabolic acidosis

m. n. o. p. q. r. s.

Crackles: FVE Anorexia: Metabolic acidosis Abdominal cramps: Metabolic acidosis Poor skin turgor: FVD Oliguria or anuria: FVD, FVE Increased specific gravity: FVD Muscle cramps, tetany: Hypocalcemia, metabolic or respiratory alkalosis

t.

Hypertonicity of muscles on palpation: Hypocalcemia, hypomagnesemia, metabolic alkalosis u. Decreased or absent deep tendon reflexes: Hypokalemia, hypercalcemia v. Increased temperature: Hypernatremia, hyperosmolar imbalance, metabolic acidosis w. Distended abdomen: Third-space syndrome x. Cold, clammy skin: FVD y. 2 edema: FVE 49. decreased cardiac output 50. acute confusion 51. deficient fluid volume 52. excess fluid volume 53. impaired gas exchange 54. risk for injury 55. deficient knowledge regarding disease management 56. impaired oral mucous membrane 57. impaired skin integrity 58. ineffective tissue perfusion 59. a. will be free of complications associated with the IV device throughout the duration of IV therapy b. will demonstrate fluid balance as evidenced by moist, mucous membranes; balanced I & O; and stable weights within 48 hours c. will have serum electrolytes within the normal range within 48 hours 60. may be appropriate when the client’s GI tract is healthy but the client cannot ingest fluids 61. clients who retain fluids and have fluid volume excess require restriction of fluids 62. include TPN, crystalloids, and colloids 63. is a nutritionally adequate hypertonic solution consisting of glucose, nutrients, and electrolytes administered peripherally, percutaneously or implanted or tunneled 64. is to correct or prevent fluid and electrolyte imbalances 65. VADs are catheters, cannulas, or infusion ports designed for repeated access to the vascular system. 66. a. Isotonic: Dextrose 5% in water, 0.9% sodium chloride (normal saline), lactated Ringer’s



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Hypotonic: 0.45% sodium chloride (half normal saline), 0.33% sodium chloride (one-third normal saline) c. Hypertonic: Dextrose 10% in water, 3%-5% sodium chloride, dextrose 5% in 0.9% sodium chloride, dextrose 5% in 0.45% NaCl sodium chloride, dextrose 5% in lactated Ringer’s



67. Infiltration Scale Grade Clinical Criteria 0

No symptoms

1

Skin blanched Edema, < 1 inch in any direction Cool to touch With or without pain

2

Skin blanched Edema 1-6 inches in any direction Cool to touch With or without pain

3

Skin blanched, translucent Gross edema >6 inches in any direction Cool to touch Mild to moderate pain Possible numbness

4

Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate to severe pain Infiltration of any amount of blood product, irritant, or vesicant

Phlebitis Scale Grade Clinical Criteria

0

No symptoms

1

Erythema at access site with or without pain

2

Pain at access site with erythema and/or edema

3

Pain at access site with erythema and/or edema


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118

Streak formation Palpable venous cord 4

Pain at access site with erythema and/or edema Streak formation Palpable venous cord >1 inch in length Purulent drainage

68. a technique in which a vein is punctured through the skin by a rigid stylet (butterfly), a stylet covered with a plastic cannula (ONC), or a needle attached to a syringe 69. are necessary for administering small hourly volumes (<20 ml/hr) and for clients who are at risk for volume overloads 70. a. keeping the system sterile b. changing solutions, tubing, and site dressings c. assisting the client with self-care activities 71. a. increase circulating blood volume after surgery, trauma, or hemorrhage b. increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia c. provide selected cellular components as replacement therapy 72. A, B, O, AB blood types 73. type O 74. AB individual 75. is an antigen antibody reaction and can range form mild response to severe anaphylactic shock, which can be life threatening 76. is the collection and reinfusion of a client’s own blood 77. a. an 18-gauge or 19-gauge cannula b. in line filter tubing c. explain the procedure and instruct the client to report any side effects d. signed informed consent e. baseline vital signs f. Two RNs must check the labels on the blood product to the client’s identification number, blood group, and complete name g. begin transfusion slowly; stay with client for the first 15 minutes h. packed RBCs transfused in 2–4 hours 78. Reaction Cause Clinical Manifestations Acute hemolytic

Infusion of ABO-incompatible whole blood, RBCs, or components containing 10 ml or more of RBCs Antibodies in the recipient’s plasma attach to antigens on transfused RBCs, causing RBC destruction

Chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, vascular collapse, hemoglobinuria, hemoglobinemia, bleeding, acute renal failure, shock, cardiac arrest, death

Febrile, nonhemoly -tic (most common)

Sensitization to donor white blood cells, platelets, or plasma proteins

Sudden chills and fever (rise in temperature of greater than 1° C), headache, flushing, anxiety, muscle pain

Mild allergic

Sensitivity to foreign plasma

Flushing, itching, urticaria


Study Guide Answer Key proteins

119 (hives)

Anaphylactic

Infusion of IgA proteins to IgAdeficient recipient who has developed IgA antibody

Anxiety, urticaria, wheezing progressing to cyanosis, shock, possible cardiac arrest

Circulatory overload

Fluid administered faster than the circulation can accommodate

Cough, dyspnea, pulmonary congestion (rales), headache, hypertension, tachycardia, distended neck veins

Sepsis

Transfusion of contaminated blood components

Rapid onset of chills, high fever, vomiting, diarrhea, and marked hypotension and shock

79. sudden chills and fever, headache, flushing, anxiety, muscle pain 80. Keep the IV line open with 0.9% NS. 81. Do not turn off the blood, and turn on NS that is connected to the Y-tubing infusion set. 82. Notify health care provider. 83. Remain with client, observing signs and symptoms; monitor VS every 5 minutes. 84. Prepare to administer emergency drugs per protocol. 85. Prepare to perform cardiopulmonary resuscitation. 86. Obtain a urine specimen and send to lab (RBC hemolysis). 87. The blood container, tubing, attached labels, and transfusion record are saved and returned to the lab. 88. 4. Extracellular fluid is all the fluid outside of the cell and has 3 compartments. 89. 3. a combination of increased PaCo2, excess carbonic acid, and an increased hydrogen ion concentration 90. 1. Any condition that results in the loss of GI fluids predisposes the client to the development of dehydration and a variety of electrolyte disturbances. 91. 3. is marked by a decreased PaCO2 and an increased pH; anxiety with hyperventilation is a cause 92. a. Steroid use – metabolic alkalosis b. Fad dieting – metabolic acidosis c. Hyperventilation – hyperventilation that occurs with conditions such as fever or anxiety causes the client to experience respiratory alkalosis by blowing off too much carbon dioxide with the increased respiratory rate. d. Chronic alcoholism – respiratory acidosis



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Chapter 42: Sleep

1. f 2. I 3. h 4. j 5. g 6. k 7. a 8. n 9. b 10. d 11. m 12. l 13. c 14. q 15. p 16. o 17. e 18. Developmental Stage Neonates

Infants

Sleep Patterns Usual Rituals The neonate up to the age of Quieting activities, such as 3 months averages about 16 holding them snugly in hours of sleep a day, sleeping blankets, singing or talking almost constantly during the softly, and gentle rocking, first week. The sleep cycle is help infants fall asleep. generally 40 to 50 minutes with wakening occurring after one to two sleep cycles. Approximately 50% of this sleep is REM sleep, which stimulates the higher brain centers. This is essential for development because the neonate is not awake long enough for significant external stimulation. Infants usually develop a Quieting activities, such as nighttime pattern of sleep by holding them snugly in 3 months of age. The infant blankets, singing or talking normally takes several naps softly, and gentle rocking, during the day but usually help infants fall asleep. sleeps an average of 8 to 10 hours during the night for a total daily sleep time of 15 hours. About 30% of sleep



121 time is in the REM cycle. Awakening commonly occurs early in the morning, although it is not unusual for an infant to awaken during the night. By the age of 2, children usually sleep through the night and take daily naps. Total sleep averages 12 hours a day. After 3 years of age, children often give up daytime naps (Hockenberry and Wilson, 2006). It is common for toddlers to awaken during the night. The percentage of REM sleep continues to fall. During this period the toddler may be unwilling to go to bed at night due to a need for autonomy or a fear of separation from their parents.

Toddlers

Preschoolers

On average a preschooler sleeps about 12 hours a night (about 20% is REM). By the age of 5, the preschooler rarely takes daytime naps except in cultures where a siesta is the custom (Hockenberry and Wilson, 2006). The preschooler usually has difficulty relaxing or quieting down after long, active days and has problems with bedtime fears, waking during the night, or nightmares. Partial wakening followed by normal return to sleep is frequent (Hockenberry and

A bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) used consistently helps young children avoid delaying sleep. Parents need to reinforce patterns of preparing for bedtime. Quiet activities such as reading stories, coloring, reading, allowing children to sit in a parent’s lap while listening to music or listening to a prayer are routines that are often associated with preparing for bed. Reading the child a bedtime story, rocking the child to sleep, or engaging in quiet play. Some young children need a special blanket or stuffed animal when going to sleep. A bedtime routine (e.g., same hour for bedtime, snack or quiet activity) used consistently helps young children avoid delaying sleep. Parents need to reinforce patterns of preparing for bedtime. Quiet activities such as reading stories, coloring, reading, allowing children to sit in a parent’s lap while listening to music or listening to a prayer are routines that are often associated with preparing for bed.



School-age children

Adolescents

Young adults

122 Wilson, 2006). In the waking period, the child exhibits brief crying, walking around, unintelligible speech, sleepwalking, or bed-wetting. The amount of sleep needed during the school years. A 6year-old averages 11 to 12 hours of sleep nightly, whereas an 11-year-old sleeps about 9 to 10 hours (Hockenberry and Wilson, 2006). The 6- or 7-year-old will usually go to bed with some encouragement or by doing quiet activities. The older child often resists sleeping because of an unawareness of fatigue or a need to be independent. On average, teenagers get about 7½ hours of sleep per night. The typical adolescent is subject to a number of changes such as school demands, after-school social activities, and part-time jobs that reduce the time spent sleeping (National Sleep Foundation, 2006b). This shortened sleep time often results in EDS. Performance in school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol are often the result of EDS due to insufficient sleep (Spilsbury and others, 2004; Walsh and others, 2005). Most young adults average 6 to 8½ hours of sleep a night. Approximately 20% of sleep time is REM sleep, which remains consistent throughout life. It is common

Adults need to avoid excessive mental stimulation just before bedtime. Reading a light novel, watching an enjoyable television program, or listening to



Middle adults

Older adults

123 for the stresses of jobs, family relationships, and social activities frequently to lead to insomnia and the use of medication for sleep. Daytime sleepiness contributes to an increased number of accidents, decreased productivity, and interpersonal problems in this age-group. Pregnancy increases the need for sleep and rest. Insomnia, periodic limb movements, restless leg syndrome, and sleepdisordered breathing are common problems during the third trimester of pregnancy (Wolfson and Lee, 2005). During middle adulthood the total time spent sleeping at night begins to decline. The amount of stage 4 sleep begins to fall, a decline that continues with advancing age. Insomnia is particularly common, probably because of the changes and stresses of middle age. Anxiety, depression, or certain physical illnesses cause sleep disturbances. Women experiencing menopausal symptoms often experience insomnia. Complaints of sleeping difficulties increase with age. More than 50% of adults 65 years or older report problems with sleep (Hoffman, 2003). Episodes of REM sleep tend to shorten. There is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have

music helps a person relax. Relaxation exercises such as slow, deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see Chapter 43). Guided imagery and praying also promote sleep for some clients.

Adults need to avoid excessive mental stimulation just before bedtime. Reading a light novel, watching an enjoyable television program, or listening to music helps a person relax. Relaxation exercises such as slow, deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see Chapter 43). Guided imagery and praying also promote sleep for some clients

Adults need to avoid excessive mental stimulation just before bedtime. Reading a light novel, watching an enjoyable television program, or listening to music helps a person relax. Relaxation exercises such as slow, deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see



124 almost no stage 4 sleep, or deep sleep. An older adult awakens more often during the night, and it takes more time for an older adult to fall asleep. The tendency to nap seems to increase progressively with age because of the frequent awakenings experienced at night.

Chapter 43). Guided imagery and praying also promote sleep for some clients

The presence of chronic illness often results in sleep disturbances for the older adult. For example, an older adult with arthritis frequently has difficulty sleeping because of painful joints. Changes in sleep pattern are often due to changes in the CNS that affect the regulation of sleep. Sensory impairment reduces an older person’s sensitivity to time cues that maintain circadian rhythms. 19. Sleepiness, insomnia, and fatigue often result as a direct effect of commonly prescribed medications, including hypnotics, diuretics, alcohol, caffeine, betaadrenergic blockers, benzodiazepines, narcotics, anticonvulsants, antidepressants, and stimulants. 20. rotating shifts will cause difficulty adjusting to the altered sleep schedule, performing unaccustomed heavy work, engaging in late-night social activities, and changing evening mealtime 21. Most persons are sleep-deprived and experience excessive sleepiness during the day, which can become pathological when it occurs at times when individuals need or want to be awake. 22. personal problems or certain situations frequently disrupt sleep; retirement, physical impairment, or the death of a loved one 23. Good ventilation is essential for a restful sleep, as are the size and firmness of the bed; light levels affect the ability to fall asleep. 24. Exercise 2 hours or more before bedtime allows the body to cool down and maintain a state of fatigue that promotes relaxation. 25. eating a large, heavy, or spicy meal at night often results in indigestion that interferes with sleep; caffeine, alcohol and nicotine produce insomnia; weight loss or weight gain



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26. clients, bed partners, and parents of children 27. a. description of sleeping problems b. usual sleep pattern c. physical and psychological illness d. current life events e. emotional and mental status f. bedtime routines g. bedtime environment h. behaviors of sleep deprivation 28. anxiety 29. ineffective breathing pattern 30. acute confusion 31. family coping 32. ineffective coping 33. fatigue 34. ineffective protection 35. disturbed sensory perception 36. sleep deprivation 37. disturbed sleep pattern 38. Client will identify factors in the immediate home environment that disrupt sleep in 2 weeks. 39. Client will report having a discussion with family members about environmental barriers to sleep in 2 weeks. 40. Client will report changes made in the bedroom to promote sleep within 4 weeks. 41. Client will report having fewer than 2 awakenings per night within 4 weeks. 42. Eliminate distracting noises; promote comfortable room temperature, ventilation, bed and mattress to provide support and firmness 43. sleep when fatigued or sleepy, bedtime routines for children, adults need to avoid excessive mental stimulation before bedtime 44. small night light, a bell at the bedside to alert family members 45. clothing, extra blankets, void before retiring 46. increasing daytime activity lessens problems with falling asleep 47. pursue a relaxing activity for adults; children need comforting and night lights 48. a dairy product that contains L-tryptophan is often helpful to promote sleep; do not drink caffeine, tea, colas, and alcohol before bedtime 49. melatonin (nutritional supplement to aid in sleep), valerian, kava 50. lights, reduce noise; also refer to Box 42-12 in the text for other examples 51. keep beds clean and dry and in a comfortable position; application of dry or moist heat; splints; and proper positioning 52. plan care to avoid awakening clients for nonessential tasks; allow clients to determine the timing and methods of delivery of basic care 53. reduce the risk of post-op complications for clients with sleep apnea (airway); use of CPAP 54. giving clients control over their health care minimizes uncertainty and anxiety; back rubs; cautious use of sedatives 55. a. observe whether a client falls asleep after reducing noise and darkening a room b. ask a client to describe the number of awakenings during the previous night c. evaluate the level of understanding that clients and families gain after receiving instructions on sleep habits 56. 2. definition of, influences the pattern of major biological and behavioral functions 57. 3. a natural protein found in milk, cheeses, and meats



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58. 4. See Box 42-4 in the text for other symptoms of sleep deprivation; most physiological symptoms are decreased, not increased. 59. 4. The related factor of the sleep disturbance is physiological for this client (leg pain). 60. 2. A sleep-promotion plan frequently requires many weeks to accomplish. 61. Julie’s statement that she is having difficulty sleeping due to her husband’s snoring is an indication of an additional sleep problem. A more in-depth assessment of David’s sleep problem, sleep habits, history, and sleep hygiene habits is needed. A 1 – 2 week sleep log or diary with entries by both Julie and David can provide additional assessment data related to the problem.



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Chapter 43: Pain Management

1. c 2. f 3. b 4. j 5. h 6. a 7. I 8. e 9. g 10. k 11. d 12. a. is protective, has a cause, is of short duration, and has limited tissue damage and emotional response b. lasts longer than anticipated, does not always have a cause, and leads to great personal suffering 13. a. pain that occurs sporadically over an extended duration of time b. is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition 14. Nociceptive pain: Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/or opioids. Somatic: comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well-localized. Visceral pain: Arises from visceral organs, such as the gastrointestinal tract and pancreas. Categories include: a. Tumor involvement of the organ capsule that causes aching and fairly welllocalized pain. b. Obstruction of hollow viscus, which causes intermittent cramping and poorly localized pain. Neuropathic pain: Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant analgesics. Deafferentation pain: Injury to either the peripheral or central nervous system. Examples: Phantom pain reflects injury to the peripheral nervous system; burning pain b elow the level of a spinal cord lesion reflects injury to the central nervous system. Sympathetically maintained pain: Associated with dysregulation of the autonomic nervous system. Examples: pain associated with reflex sympathetic dystrophy/causalgia (complex regional pain syndrome, type I, type II). Polyneuropathies: Client feels pain along the distribution of many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barré syndrome. Mononeuropathies: Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia. 15. a. age b. fatigue c. genes d. neurological function 16. a. attention b. previous experience c. family and social support



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17. active searching for meaning, concerns of loss loss of independence independence and becoming a burden to the family 18. a. anxiety anxiety b. coping coping styles styles 19. a. meaning meaning of the pain b. ethnicity ethnicity 20. A: A A: Ask sk about pain regularly. A regularly. Assess ssess pain systematically. B: B B: Believe elieve the client and family in their report of pain and what relieves it. C: C hoose hoose pain-control options appropriate for the client, family, and setting. D: D D: Deliver eliver interventions in a timely, logical, and coordinated fashion. E: E E: E mpower mpower clients and their families. E families. E nable nable them to control their course to the greatest extent possible. 21. a. onset and duration b. location c. intensity intensity d. quality e. pain pattern f. relief measures g. contributing symptoms h. effects of pain on the client i. behavioral effects j. influence on activities of daily living 22. anxiety anxiety 23. fatigu fatiguee 24. hopeles hopelessne sness ss 25. impaired impaired physical physical mobility mobility 26. imbalanced imbalanced nutrition: nutrition: less than 27. powerlessnes powerlessnesss 28. chronic chronic low self-estee self-esteem m 29. disturbed disturbed sleep sleep pattern pattern 30. impaired impaired social interacti interaction on 31. spiritual spiritual distre distress ss 32. reports that pain is a 3 or less on a scale of 0-10, does not interfere interfere with ADLs, or personal pain intensity goal attained 33. identifies factors that intensify pain and modifies modifies behavior accordingly 34. uses pain-relief pain-relief measures measures safely 35. a. find such interventions appealing b. express anxiety or fear c. will possibly benefit benefit from avoiding or reducing drug therapy d. are likely to experience and need to cope with a prolonged interval of postoperative pain e. have incomplete pain relief after use of pharmacological interventions 36. is mental and physical freedom from tension or stress stress that provides individuals individuals with a sense of self-control 37. directs a client’s attention attention to something other than pain and thus reduces the awareness of pain 38. diverts the person’s attention attention away from the pain and creates a relaxation response 39. a massage, warm bath, ice bag, and TENS stimulates the skin skin to reduce pain perception by the release of endorphins, which block the transmission of painful stimuli 40. not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements 41. One simple way to promote promote comfort is by removing removing or preventing painful stimuli; stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback 42. a. nonopioids b. opioids c. adjuvants/coanalgesics



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43. a variety of medications that enhance analgesics or have analgesic properties that were originally unknown 44. allows clients to self-administer self-administer opioids with minimal risk of overdose; the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing 45. manage pain from a variety of surgical procedures with a pump that that is set as a demand or continuous mode and left in place for 48 hours 46. EMLA via a disc or thick thick cream to the skin for 30 to 60 minutes before minor minor procedures 47. local infiltration of an anesthetic medication to induce loss of sensation to a body part 48. is the injection of a local anesthetic to block a group of sensory nerve fibers 49. it permits control or reduction of severe pain and reduces the client’s overall opioid requirement; can be short- or long-term 50. nausea and vomiting, urinary urinary retention, constipation, constipation, respiratory depression, and pruritus 51. a. Prevent catheter displacement: Secure catheter (if not connected to implanted reservoir) carefully to outside skin. b. Maintain catheter function: Check external dressing around catheter site for dampness or discharge. (Leak of cerebrospinal fluid may develop.) c. Prevent infection: Use strict aseptic technique when caring for catheter (see Chapter 33). d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy. e. Prevent undesirable complications: Assess for pruritus (itching) and nausea and vomiting. f. Maintain urinary and bowel function: Monitor intake and output. 52. a. 100 times more potent than than morphine in predetermined doses that provide provide analgesic for 48-72 hours; useful when unable unab le to take oral medications b. to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed 53. Incident pain: Pain that is predictable and elicited by specific b ehaviors such as physical therapy or wound-dressing changes End-of-dose failure pain: Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic Spontaneous pain: Pain that is unpredictable and not no t associated with any activity or event 54. Client: Fear of addiction, Worry about side effects, Fear of tolerance (won’t be there when I need it), Take too many pills already, Fear of injections, Concern about not being a “good” client, Don’t want to worry family and friends, May need more tests, Need to suffer to be cured, Pain is for past indiscretions, Inadequate education, Reluctance to discuss pain, Pain is inevitable, Pain is part of aging, Fear of disease progression, Primary health care providers and nurses are doing all that they can, Just forget to take analgesics, Fear of distracting primary health care providers from treating illness, Primary health care providers have more important or ill clients to see, Suffering in silence is noble and expected Health care provider: Inadequate pain assessment, Concern with addiction, Opiophobia (fear of opioids), Fear of legal repercussions, No visible cause of pain, Clients must learn to live with pain, Reluctance to deal d eal with side effects of analgesics, Fear of giving a dose that will kill the client, Not believing the client’s report of pain, Primary health care provider time



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constraints, Inadequate reimbursement, Belief that opioids “mask” symptoms, Belief that pain is part of aging, Overestimation of rates of respiratory depression Health care system barriers: Concern with creating “addicts,”, Ability to fill prescriptions, Absolute dollar restriction on amount reimbursed for prescriptions, Mail order pharmacy restrictions, Nurse practitioners and physician assistants not used efficiently, Extensive documentation requirements, Poor pain policies and procedures regarding pain management, Lack of money, Inadequate access to pain clinics, Poor understanding of economic impact of unrelieved pain 55. physical dependence: A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Addiction: A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction: Client behaviors (drug seeking) that occur when pain is undertreated. Pseudotolerance: Need to increase opioid dose for reasons other than opioid tolerance: progression of disease, onset of new disorder, increased p hysical activity, lack of adherence, change in opioid formulation, drug-drug interaction, drug-food interaction. 56. a medication or procedure that produces positive positive or negative effects in clients that are not related to the placebo’s specific physical or chemical properties 57. treat persons on an inpatient or outpatient basis; multidisciplinary multidisciplinary approach to find the most effective pain-relief measures 58. the goal is to live live life fully with with an incurable condition 59. care of clients at the the end of life, which emphasizes quality quality of life over quantity quantity 60. evaluate the client for the effectiveness effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the client’s perception of pain 61. 2. Only the client knows whether pain is present and what the experience is like. 62. 1. Once the brain perceives pain, there is is a release of inhibitory inhibitory neurotransmitters such as endogenous opioids (e.g., endorphins) which hinder the transmission of pain and help produce an analgesic effect. 63. 2. A client’s self-report self-report of pain is the the single most reliable reliable indicator of the existence and intensity of pain. 64. 2. The reticular activating system system inhibits painful stimuli if a person person receives sufficient or excessive sensory input; with sufficient sensory stimulation a person is able to ignore or become unaware of pain. 65. 3. Developmental differences are found between age groups; therefore, the the nurse needs to adapt approaches for assessing a child’s pain and how to prepare a child for a painful procedure. 66. Mrs. Mays, 75 years old, was diagnosed with a cancerous tumor in her left lung 2 months ago. She also has a history of osteoarthritis. After chemotherapy and radiation therapy, she



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was taking ibuprofen 200mg on a prn basis. Until today she was able to clean her home and climb the stairs to her bedroom without difficulty. She also maintained her body weight and slept well through the night. However, she is now admitted to the hospital with uncontrollable chest pain and possible pneumonia. Prior to being admitted to the hospital, her pain escalated from a 3 to a 10, so she doubled her medication and went to bed, but this did not help. Currently her pain is a 9 on a 1-10 scale. She responds that she is unable to complete her own hygiene activities, sleep, or eat well. She is restless , unable to stay focused, and remains very still, muscles tense and frowning, during the history taking. She says that a pain intensity of 5 out of 10 helps her function better right now, although a goal of 3 is preferable.



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Chapter 44: Nutrition

1. c 2. h 3. I 4. n 5. o 6. j 7. k 8. v 9. d 10. s 11. p 12. f 13. m 14. e 15. r 16. q 17. n 18. g 19. l 20. u 21. t 22. a 23. b 24. f 25. h 26. b 27. g 28. l 29. k 30. j 31. m 32. d 33. e 34. c 35. a 36. i 37. a. is the recommended amount of nutrition that appears sufficient to maintain a specific body function for 50% of the population based on age and gender b. is the average needs of 98% of the population, not the individual c. suggested intake for individuals based on observed or experimental determined estimates of nutrient intakes d. is the highest level that likely poses no risk of adverse health events



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38. a. Adopt a balanced eating pattern with a variety of nutrient-dense food and beverages among the basic food groups. b. Maintain body weight in a healthy range. c. Encourage physical activity, and decrease sedentary activities. d. Encourage fruits, vegetables, whole-grain products, and fat-free or low-fat milk while staying within energy needs. e. Keep total fat intake between 20-35 % of total calories, with most fats coming from polyunsaturated or monosaturated fatty acids. f. Choose and prepare foods and beverages with little added sugars or sweeteners. g. Choose and prepare foods with little salt while at the same time eating potassium-rich foods. h. Limit intake of alcohol. i.

Practice food safety to prevent microbial food-borne illness.

39. a. reduced food allergies and intolerances b. fewer infant infections c. easier digestion d. convenient, correct temperature, available and fresh e. economical f. increases time for mother and infant interaction 40. causes GI bleeding, is too concentrated for infant’s kidneys to manage, increases the risk of mild product allergies, poor source of iron and vitamin C and E 41. are potential sources of botulism toxin and should not be used in the infant’s diet 42. a. the infant’s needs b. physical readiness to handle different forms of foods c. detect and control allergic reactions 43. a. diet rich in high-calorie foods b. inactivity c. genetic predisposition c. use of food for coping mechanism for stress or boredom d. family and social factors 44. a. body image and appearance b. desire for independence c. eating at fast-food restaurants d. peer pressure e. fad diets 45. a. Anorexia nervosa: Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight less than 85% Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.


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of IBW; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected; Intense fear of gaining weight or becoming fat, although underweight; Disturbance in the way in which one’s body weight, size, or shape is experienced, e.g., the person claims to “feel fat” even when emaciated, believes that one area of the body is “too fat” even when obviously underweight; In females, absence of at least 3 consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) b. Bulimia nervosa: Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time); A feeling of lack of co ntrol over eating behavior during the eating binges; The person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain; A minimum average of 2 binge eating episodes a week for at least 3 months. 46. is important for DNA synthesis and the growth of RBCs, inadequate intake will lead to possible neural tube defects, anencephaly or maternal; megaloblastic anemia 47. a. Age-related gastrointestinal changes that affect digestion of food and maintenance of nutrition include changes in the teeth and gums, reduced saliva production, atrophy of oral mucosal epithelial cells, increased taste threshold, decreased thirst sensation, reduced gag reflex, and decreased esophageal and colonic peristalsis b. The presence of chronic illnesses (e.g., diabetes mellitus, end-stage renal disease, cancer) often affect nutrition intake. c. Malnutrition in older adults has multiple causes, such as income, educational level, physical functional level to meet activities of daily living (ADLs), loss, dependency, loneliness, and transportation. d. Adverse effects of medications cause problems such as anorexia, xerostomia, early satiety, and impaired smell and taste perception. e. Factors affecting nutrient needs: Calcium, vitamin D, or phosphorus for basic metabolic demand (BMD). B12 may not be synthesized because of lack of intrinsic factor in terminal ileum, decreased lean muscle mass, lower basic energy expenditure (BEE) f. Cognitive impairments such as delirium, dementia, and depression affect ability to obtain, prepare, and eat healthy foods. 48. avoid meat, fish, and poultry but eat eggs and milk 49. drink milk but avoid eggs 50. eat primarily brown rice, other grains, and herb teas 51. eat only fruits, nuts, honey, and olive oil 52. a. screening for malnutrition for risk factors (unintentional weight loss, presence of a modified diet, presence of nutrition impact symptoms b. anthropometry (size and make- up of the body) c. BMI d. lab and biochemical tests (albumin, transferring, prealbumin, retinal binding protein, total iron-binding capacity, and hemoglobin)



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e. dietary history 53. difficulty swallowing (neurogenic, myogenic, and obstructive causes) 54. a. general appearance: Listless, apathetic, cachectic b. weight: Obesity (usually 10% above IBW) or underweight (special concern for underweight) c. posture: Sagging shoulders; sunken chest; humped back d. muscles: Flaccid, poor tone, underdeveloped tone; “wasted” appearance; impaired ability to walk properly e. nervous system: Inattention; irritability; confusion; burning and tingling of hands and feet (paresthesia); loss of position and vibratory sense; weakness and tenderness of muscles (may result in inability to walk); decrease or loss of ankle and knee reflexes; absent vibratory sense f. gastrointestinal: Anorexia; indigestion; constipation or diarrhea; liver or spleen enlargement g. cardiovascular: Rapid heart rate (above 100 beats/min), enlarged heart; abnormal rhythm; elevated blood pressure h. general vitality: Easily fatigued; no energy; falls asleep easily, tired and apathetic i. hair: Stringy, dull, brittle, dry, thin, and sparse, depigmented; easily plucked j. skin: Rough, dry, scaly, pale, pigmented, irritated; bruises; petechiae; subcutaneous fat loss k. face and neck: Greasy, discolored, scaly, swollen; dark skin over cheeks and under eyes; lumpiness or flakiness of skin around nose and mouth l. lips: Dry, scaly, swollen; redness and swelling (cheilosis); angular lesions at corners of mouth; fissures or scars (stomatitis) m. mouth, oral membranes: Swollen, boggy oral mucous membranes n. gums: Spongy gums that bleed easily; marginal redness, inflammation; receding o. tongue: Swelling, scarlet and raw; magenta, beefiness (glossitis); hyperemic and hypertrophic papillae; atrophic papillae p. teeth: Unfilled caries; missing teeth; worn surfaces; mottled (fluorosis), malpositioned q. eyes: Eye membranes pale (pale conjunctivas); redness of membrane (conjunctival injection); dryness; signs of infection; Bitot’s spots, redness and fissuring of eyelid corners (angular palpebritis); dryness of eye membrane (conjunctival xerosis); dull appearance of cornea (corneal xerosis); soft cornea (keratomalacia) r. neck (glands): Thyroid or lymph node enlargement s. nail: Spoon shape (koilonychia); brittleness; ridges t. legs, feet: Edema; tender calf; tingling; weakness u. skeleton: Bowlegs; knock-knees; chest deformity at diaphragm; prominent scapulae and ribs 55. risk for aspiration 56. constipation 57. diarrhea 58. health-seeking behaviors 59. deficient knowledge 60. imbalanced nutrition: less than body requirements



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61. imbalanced nutrition: more than body requirements 62. risk for imbalanced nutrition: more than body requirements 63. readiness for enhanced nutrition 64. feeding self-care deficit 65. a. nutritional intake meets the minimal DRIs b. fat nutritional intake is less than 30% c. removes sugared beverages from the diet d. refrains from eating unhealthy foods between meals and after dinner e. loses at least ½ to 1 pound per week 66. a. botulism: Improperly home-canned foods, smoked and salted fish, ham, sausage, shellfish b. escherichia: Undercooked meat (ground beef) c. listeriosis: Soft cheese, meat (hot dogs, pate, lunch meats), unpasteurized milk, poultry, seafood d. perfringens enteritis: Cooked meats, meat dishes held at room or warm temperature e. salmonellosis: Milk, custards, egg dishes, salad dressings, sandwich fillings, polluted shellfish f. shigellosis: Milk, milk products, seafood, salads g. staphylococcus: Severe abdominal cramps, pain, vomiting, diarrhea, perspiration, headache, fever, prostration. Appears 1-6 hou rs after ingestion and lasts 1-2 days 67. decreased level of alertness, decreased gag and/or cough reflexes, and clients who have difficulty managing saliva 68. a. dysphagia puree b. dysphagia mechanically altered c. dysphagia advanced d. regular 69. a. thin liquids (low viscosity) b. nectar-like liquids (medium viscosity) c. honey-like liquids d. spoon-thick liquids (pudding) 70. a. (1.0-2.0 kcal/mL) milk-based blenderized foods b. (3.8 – 4.0 kcal/mL) single macronutrient preparations, not nutritionally complete c. (1.0-3.0 kcal/mL) predigested nutrients that are easier for a partially dysfunctional GI tract to absorb d. (1.0-2.0 kcal/mL) designed to meet specific nutritional needs in certain illnesses 71. a. reduces sepsis b. minimizes the hypermetabolic response to trauma c. maintains intestinal structure and function 72. a. appropriate assessment of nutrition needs



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b. meticulous management of the CVC line c. careful monitoring to prevent or treat metabolic complications 73. provide supplemental kcal and prevent fatty acid deficiencies 74. a. Pulmonary aspiration: Regurgitation of formula, Feeding tube displaced, Deficient gag reflex, Delayed gastric emptying b. Diarrhea: Hyperosmolar formula or medications, Antibiotic therapy, Bacterial contamination, Malabsorption c. Constipation: Lack of fiber, Lack of free water, Inactivity d. Tube occlusion: Pulverized medications given per tube, Sedimentation of formula, Reaction of incompatible medications or formula e. Tube displacement: Coughing, vomiting, Not taped securely f. Abdominal cramping, nausea/vomiting: High osmolality of formula, Rapid increase in rate/volume, Lactose intolerance, Intestinal obstruction, High-fat formula used, Cold formula used g. Delayed gastric emptying: Diabetic gastroparesis, Serious illnesses, Inactivity h. Serum electrolyte imbalance: Excess GI losses, Dehydration, Presence of disease states such as cirrhosis, renal insufficiency, heart failure, or diabetes mellitus i. Fluid overload: Refeeding syndrome in malnutrition, Excess free water or diluted (hypotonic) formula j. Hyperosmolar dehydration: Hypertonic formula with insufficient free water 75. a. Electrolyte imbalance: Monitor Na, Ca, K, Cl, PO4, Mg, and CO2 levels b. Hypercapnia: Increased oxygen consumption, increased CO2, respiratory quotient >1.0, minute ventilation c. Hypoglycemia: Diaphoresis, shakiness, confusion, loss of consciousness d. Hyperglycemia: Thirst, headache, lethargy, increased urination e. Hyperglycemic hyperosmolar nonketotic dehydration/coma (HHNC): Hyperglycemia (>500 mg/dl), glycosuria, serum osmolarity >350 mOsm/L, confusion, azotemia, headache, severe signs of dehydration (see Chapter 41), hypernatremia, metabolic acidosis, convulsions, coma 76. once the client meets 1/3 to ½ of their kcal needs per day, PN is usually decreased to ½ the original volume; increase the EN to meet needs (75%) 77. is the use of nutritional therapies to treat an illness, injury, or condition 78. is a bacteria that causes peptic ulcers and is confirmed by lab tests, treated with antibiotics 79. Crohn’s disease and ulcerative colitis: treat with elemental diets or PN, supplemental vitamins, and iron. Manage by increasing fiber, reducing fat, avoiding large meals, and avoiding lactose, 80. celiac disease, gluten-free diet 81. treat with moderate-to-low residue and high-fiber diet 82. carbohydrates 45-75%, limit fat to less than 7%, cholesterol less than 200 mg/day 83. balancing caloric intake with exercise; diet high in fruits, vegetables, and whole-grain fiber; fish at least twice per week; limit food high in added sugar and salt 84. goal is to meet the increased metabolic needs of the client by maximizing intake of nutrients and fluids



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85. small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods 86. ongoing comparisons need to be made with baseline measures of weight, serum albumin, and protein and kcal intake, changes in condition 87. 4. Each gram of CHO produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise , erythrocyte and leukocyte production, and cell function of the renal medulla 88. 3. is when the intake of nitrogen is greater than the output, which is used for building, repairing, and replacing body tissues 89. 4. the growth rate slows during the toddler years (1-3) and therefore needs fewer kcal but an increased amount of protein in relation to body weight; appetite often decreases at 18 months of age 90. 1. All of the other clients are at risk for a nutritional imbalance. 91. 2. The measurement of pH of secretions withdrawn from the feeding tubes helps to differentiate the location of the tube. 92. 2. the recommended diet from the AHA to reduce risk factors for the development of hypertension and coronary heart disease 93. Mrs. Cooper, who is 68 years old and has a history of congestive heart failure. Recently Mrs. Cooper noticed a weight loss (15%). Three months have passed since Mrs. Cooper started taking sertraline for depression related to the loss of her husband 6 months ago. Mrs. Cooper was also referred for counseling 3 months ago for help with grief and depression through a local senior service agency. When Maria inquired as to her financial situation, Mrs. Cooper responded that it was tight living on a small pension and Social Security, but she was able to manage. Mrs. Cooper states that she drinks some juice in the morning and two or three cups of coffee. In addition, she often has a sandwich in the late afternoon. Mrs. Cooper states, “I’m just not interested in food. It has no taste.” Mrs. Cooper complains of loneliness and said she does not get out much, although her psychologist recommended more socializing. Her friends at church call her to come back to meetings, but she is just not ready. She says she tires easily. She has lost 24 pounds over the past 6 months. Her weight is 20% below her IBW and her BMI is 17. Mrs. Cooper has stooped posture; dull, thinning hair; dry, scaling skin; pale conjunctivae and mucous membranes; 2+ bilateral pitting ankle edema; and generalized poor muscle tone. Goals for this patient include gaining 1 to 2 pounds per month until goal of 130 pounds is reached by consuming 1900 kcal/day, including 50 g of protein per day. Her physical assessment and laboratory values will be within n ormal limits. In order to accomplish these goals, the nurse practitioner will coordinate plan of care with healthcare provider, psychologist, and registered dietitian. She will individualize her menu plans and teach Mrs. Cooper about the food pyramid. Mrs. Cooper will be monitored monthly for weight gain, anemia, serum albumin level, and total lymphocyte count (TLC). She will encourage client to eat small meals and to increase dietary intake, including fluids and fiber, to help offset anorexia secondary to sertraline. The nurse practitioner will encourage Mrs. Cooper to eat lunch at the senior center 5 times per week.



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Chapter 45: Urinary Elimination

1. 2. 3. 4. 5. 6. 7. 8.

d c g f b e a a. pathological conditions (acute, chronic) b. sociocultural factors c. psychological factors d. fluid balance e. surgical and diagnostic procedures 9. an increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions 10. Renal failure that can no longer be controlled by conservative management (i.e., dietary modifications and administration of medications to correct electrolyte abnormalities), Worsening of uremic syndrome associated with ESRD (i.e., nausea, vo miting, neurological changes, pericarditis), Severe electrolyte and/or fluid abnormalities that cannot be con trolled by simpler measures (e.g., hyperkalemia, pulmonary edema) 11. awakening to void one or more times at night b. an excessive amount of urine c. urine output < intake d. no urine 12. surgical formation (temporary or permanent) that bypasses the bladder, has a stoma on the abdomen to drain the urine 13. is an accumulation of urine resulting from an inability of the bladder to empty properly 14. hospital-acquired result from catheterization or surgical manipulation, Escherichia coli most common pathogen 15. retained urine in the bladder from kinked, obstructed, or clamped catheter 16. dysuria, fever, chills, nausea, vomiting and malaise, cystitis, hematuria 17. trauma, cancer of the bladder, radiation to the bladder, fistulas, or chronic cystitis 18. ureters are implanted into the isolated segment of ileum and used as a conduit for continuous drainage, the client wears a stomal pouch continuously 19. a tube is placed directly into the renal pelvis to drain urine directly from one or both of the kidneys 20. a. pattern of urination b. symptoms of urinary alterations c. factors affecting urination 21. j 22. e 23. g 24. I 25. h 26. k 27. l 28. b 29. d 30. f 31. a



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32. c 33. skin and mucosal membranes, kidneys, bladder, urethral meatus 34. pale, straw-colored to amber-colored depending on its concentration 35. appears transparent at voiding; becomes more cloudy on standing in a container 36. has a characteristic odor; the more concentrated the urine, the stronger the odor 37. a. Random: Collect during normal voiding from an indwelling catheter or urinary diversion collection bag. Use a clean specimen cup. b. Clean-voided or midstream: Use a sterile specimen cup. Female – After donning sterile gloves, spread labia with thumb and forefinger of nondominant hand. Cleanse area with cotton ball or gauze, moving from front (above urethral orifice) to back (toward anus). Using a fresh swab each time, repeat front-to-back motion three times (begin with center, then left side then right side). If agency policy indicates, rinse area with sterile water, and dry with dry cotton ball or gauze.While continuing to hold labia apart, have client initiate stream. After client achieves a stream, pass container into stream and collect 30 to 60 ml. Remove specimen container before flow of urine stops and before releasing labia or penis. Client finishes voiding in bedpan or toilet. Male – After donning sterile gloves, hold penis with one hand, and using circular motion and antiseptic swab, cleanse end of penis, moving from center to outside (see illustration). In uncircumcised men, retract the foreskin before cleansing. If agency procedure indicates, rinse area with sterile water, and d ry with cotton or gauze. After client has initiated urine stream, pass specimen collection container into stream, and collect 30 to 60 ml. Remove specimen container before flow of urine stops and before releasing labia or penis. Client finishes voiding in bedpan or toilet. c. Sterile: If the client has an indwelling catheter, collect a sterile specimen by using aseptic technique through the special sampling port (Figure 45-7) found on the side of the catheter. Clamp the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After the nurse wipes the port with an antimicrobial swab, insert a sterile syringe hub and withdraw at least 3 to 5 ml of urine (check agency policy). Using sterile aseptic technique, transfer the urine to a sterile co ntainer. d. Timed urine: Time required may be 2-, 12-, or 24-hour collections. The timed period begins after the client urinates and ends with a final voiding at the end of the time period. The client voids into a clean receptacle, and the urine is transferred to the special collection container, which often contains special preservatives. Each specimen must be free of feces and toilet tissue. Missed specimens make the whole collection inaccurate. Check with agency policy and the laboratory for specific instructions. 38. will analyze values of pH (4.6-8.0), protein (none or up to 8 mg/100 ml), glucose (none), ketones (none), blood, specific gravity (1.0053-1.030) and microscopic values for RBCs (up to 2), WBCs (0-4 per low-power field), bacteria (none), casts (none), and crystals (none). 39. is the weight or degree of concentration of a substance compared with an equal volume of water 40. sterile or clean voided sample of urine and can report bacterial growth in 24-48 hours 41.



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a. Abdominal roentgenogram: Determine the size, shape, symmetry, and location of the kidneys. b. Intravenous pyelogram (IVP): View the collecting ducts and renal pelvis and outline the ureters, bladder, and urethra. A special intravenous injection (iodine-based) that converts to a dye in urine is injected intravenously. c. urodynamic testing: Determine bladder muscle function. This procedure is indicated to evaluate causes of urinary incontinence. Generally the client urinates into a toilet equipped with a funnel and uroflowmeter. Voiding activates the uroflowmeter, and electronic data is recorded and analyzed. d. CT scan: Obtain detailed images of structures within a selected plane of the body. The computer reconstructs cross-sectional images and thus allows the health care provider to view pathologic conditions such as tumors and obstructions. e. Ultrasound: Renal – Identify gross renal structures and structural abnormalities in the kidney using high-frequency, inaudible sound waves. Bladder – Identify structural abnormalities of bladder or lower urinary tract. Can also be used to estimate the volume of urine in the bladder. 42. endoscopy: Direct visualization, specimen collection, and/or treatment of the interior of the bladder and urethra. Although this procedure is usually performed using local anesthesia, general anesthesia or conscious sedation is more common to avoid unnecessary anxiety and trauma for the client. Surgery on the male prostate is also performed using a special endoscope. Arteriogram: Visualizes the renal arteries and/or their branches to detect narrowing or occlusion. A catheter is placed in one of the femoral arteries and introduced up to the level of the renal arteries. Radio-opaque contrast is injected through the catheter while xray images are taken in rapid succession. 43. disturbed body image 44. urinary incontinence (functional, stress, urge) 45. pain (acute, chronic) 46. risk for infection 47. self-care deficit, toileting 48. impaired skin integrity 49. impaired urinary elimination 50. urinary retention 51. a. client will void within 8 hours b. urinary output of 300 ml or greater will occur with each voiding c. client’s bladder is not distended to palpation 52. a. normal positioning b. running water c. stroking the inner aspect of the thigh d. warm water over the client’s perineum 53. functional: Clothing modifications, environmental alterations, scheduled toileting, absorbent products stress: Pelvic floor exercises (Kegel), surgical interventions, biofeedback, electrical stimulation, absorbent products urge: Antimuscarinic agents, behavioral interventions, biofeedback, bladder retraining, pelvic floor exercises, lifestyle modifications (smoking cessation, weight loss, and fluid modifications), absorbent products



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mixed: Main treatments will usually be based on the symptoms that are most bothersome to client reflex: Intermittent catheterization, condom catheter (male), Credé’s method 54. meat, eggs, whole-grain breads, cranberries, and prunes 55. intermittent: Relief of discomfort of bladder distention, provision of decompression; Obtaining sterile urine specimen when clean-catch specimen is unobtainable; Assessment of residual urine after urination; Long-term management of clients with spinal cord injuries, neuromuscular degeneration, or incompetent bladders short-term indwelling: Obstruction to urine outflow (e.g., prostate enlargement); Surgical repair of bladder, urethra, and surrounding structures; Prevention of urethral obstruction from blood clots after genitourinary surgery; Measurement of urinary output in critically ill clients; Continuous or intermittent bladder irrigations long-term indwelling: Severe urinary retention with recurrent episodes of UTI; Skin rashes, ulcers, or wounds irritated by contact with urine; Terminal illness when bed linen changes are painful for client 56. personal hygiene at least BID for a client with an indwelling catheter with soap and water 57. special care TID and after defecation 58. 2000-2500 ml if permitted 59. to maintain the patency of indwelling catheters; blood, pus, or sediment can collect within the tubing and result in bladder distention and buildup of stagnant urine 60. surgical placement of a catheter through the abdominal wall above the symphysis pubis and into the urinary bladder 61. suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying 62. improves the strength of pelvic muscles and consists of repetitive contractions of muscle groups; effective in treating stress incontinence, overactive bladders, and mixed causes of urinary incontinence 63. is to reduce the voiding frequency and to increase the bladder capacity, specific for clients with urge incontinence related to overactive bladder 64. benefits clients with functional incontinence, by improving voluntary control over urination 65. clients with chronic disorders such as spinal cord injuries; must be able to physically manipulate equipments and assume positions 66. evaluate for change in the client’s voiding pattern and continued presence of urinary tract alterations 67. 2. involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contraction 68. 1. pain or burning (dysuria) as well as fever, chills, N/V, and malaise 69. 3. symptoms of an allergic response 70. 4. Antibiotics help the situation; the other choices are interventions to teach the client to prevent UTI. 71.



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Mrs. Grayson is a 55-year-old woman who has had problems with stress incontinence for the past 2 years. She has not spoken to anyone about her problems because she is embarrassed. She has recently begun Kegel’s exercises to a ttempt improvement in her urinary control. The nurse had the client describe situations that accompany urine leakage. Mrs. Grayson finally confides to her healthcare practitioner that the p roblem is causing her to avoid social situations and that she would like help to regain urinary control. She responds, “I find myself being embarrassed and frustrated for losing control. If my bladder is a little full, I dribble easily just picking something up or when I’m on my way to the bathroom. I’m afraid to laugh any more as that is another time I leak urine. At work I try to avoid being close to my coworkers because I am afraid I might have an odor.” The nurse asks Mrs. Grayson what she has been doing about her condition. She states that she has been wearing “one of those little pads” all the time now. The nurse asks Mrs. Grayson about any other effects that her leakage has caused. Mrs. Grayson begins to cry and states, “You know, I don’t even like to go out to the movies or a party anymore. It is safer to stay home. I have problems being intimate with my husband because of leaking. We used to go to dancing occasionally but we don’t do that anymore.” The nurse takes a focused nursing history, addressing urinary leakage and other lower urinary tract symptoms. The report of urine leakage upon physical exertion, sneezing, and laughing increases the likelihood of a diagnosis of stress incontinence. Her risk factors for this condition include a history of three pregnancies, being postmenopausal, and being overweight (200 lbs and 5’ 1” tall). The history will help define the proper interventions.



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Chapter 46: Bowel Elimination

1. Teeth masticate food, breaking it down to swallow, and saliva is produced to dilute and soften the food for easier swallowing 2. The bolus of food travels down and is pushed along by peristalsis, which propels the food through the length of the GU tract. 3. stores swallowed food and liquid, mixing of food, liquid and digestive juices, and empties its contents into the small intestine; produces HCL, mucus, a nd pepsin and intrinsic factor, which is essential for the absorption of Vitamin B12 4. segmentation and peristaltic movement facilitate both digestion and absorption; chime mixes with digestive juices 5. lower GI tract (colon) divided into the cecum, colon, and rectum. It is the primary organ of elimination. 6. contraction and relaxation of the internal and external sphincters, innervated by sympathetic and parasympathetic stimuli, aid in control of defecation 7. at the time of defecation, the external sphincter relaxes and the abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Pressure can be exerted to expel forces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. 8. a. mouth: Decreased chewing and decreased salivation, including oral dryness b. esophagus: Reduced motility, especially in lower third c. stomach: Decrease in acid secretions, motor activity, mucosal thickness, nutrient absorption d. small intestine: Increase in pouches on the weakened intestinal wall called diverticulosis e. large intestine: Constipation, Missed defecation signal increasing risk for fecal incontinence f. liver: Size decreased 9. a non-digestible residue in the diet that provides the bulk of fecal material (whole grains, fresh fruits, and vegetables) 10. persons who lack the enzyme needed to digest the milk sugar 11. fluid liquefies the intestinal contents, easing its passage through the colon, reduced fluid intake slows the passage of food through the intestine and results in hardening of stool contents 12. promotes peristalsis; weakened abdominal and pelvic floor muscles impair the ability to increase intra-abdominal pressure and to control the external sphincter 13. ulcerative colitis, irritable bowel syndrome, certain gastric and duodenal ulcers, and Crohn’s disease 14. a. a busy work schedule b. hospitalized clients who lack privacy C. sights and sounds and odors of toilet facilities d. embarrassment of using bedpan s 15. hemorrhoids, rectal surgery, rectal fistulas, and abdominal surgery 16. general anesthetic agents used during surgery cause temporary cessation of peristalsis; direct manipulation of the bowel temporarily stops peristalsis (paralytic ileus) 17.



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a. Dicyclomine HCl (Bentyl): Suppresses peristalsis and decreases gastric emptying b. Narcotics: Slow peristalsis and segmental contractions, often resulting in constipation c. Anticholinergics: Inhibit gastric acid secretion and depress GI motility. Although useful in treating hyperactive bowel disorders, anticholinergics cause constipation. d. Antibiotics: Produce diarrhea by disrupting the normal bacterial flora in the GI tract. An increase in the use of fluoroquinolones in recent years has provided a selective advantage for the epidemic of C. difficile. e. NSAIDs: Cause gastrointestinal irritation that increases the incidence bleeding with serious consequences to the elderly f. aspirin: A prostaglandin inhibitor, it interferes with the formation and production of protective mucus and causes GI bleeding. g. Histamine2 (H2) antagonists: Suppress the secretion of hydrochloric acid and interfere with the digestion of some foods h. iron: Causes discoloration of the stool (black), nausea, vomiting, constipation, (diarrhea is less commonly reported), and abdominal cramps. 18. colonoscopy and endoscopy 19. improper diet, reduced fluid intake, lack of exercise, certain medications 20. infrequent bowel movements < 3 days, difficulty passing stools, excessive straining, inability to defecate at will, hard feces 21. a. Irregular bowel habits and ignoring the urge to defecate b. Chronic illnesses (e.g., Parkinson’s disease, multiple sclerosis, rheumatoid arthritis, chronic bowel diseases, depression, diabetic neuropathy, eating disorders) c. Low-fiber diet high in animal fats (e.g., meats, dairy products, eggs). Also, low fluid intake slows peristalsis. d. Anxiety, depression, cognitive impairment e. Lengthy bed rest or lack of regular exercise f. Laxative misuse g. Older adults experience slowed peristalsis, loss of abdominal muscle elasticity, and reduced intestinal mucus secretion. Older adults often eat low-fiber foods. h. Neurological conditions that block nerve impulses to the colon (e.g., spinal cord injury, tumor) i. Organic illnesses such as hypothyroidism, hypocalcemia, or hypokalemia j. Medications such as anticholinergics, antispasmodics, anticonvulsants, antidepressants, antihistamines, antihypertensives, antiparkinsonism drugs, bile acid sequestrants, diuretics, antacids, iron supplements, calcium supplements, and opioids slow colonic action. 22. a. abdominal, GYN, or rectal surgery b. cardiovascular disease c. elevated intraocular pressure d. increased intracranial pressure 23. a collection of hardened feces wedged in the rectum that a person cannot expel as a result of unrelieved constipation 24. a. oozing of diarrhea b. loss of appetite (anorexia) c. nausea and/or vomiting d. abdominal distention and cramping e. rectal pain 25. is an increased number of stools and the passage of liquid, unformed feces associated with disorders affecting digestion, absorption, and secretion



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26. a. contamination and risk of skin ulceration b. fluid and electrolyte or acid-base imbalances 27. a causative agent of mild diarrhea to severe colitis acquired by the use of antibiotics, chemotherapy, invasive bowel procedures, or from a health care worker’s hands or direct contact with environmental surfaces 28. a. is the inability to control passage of feces and gas from the anus caused by physical conditions that impair anal sphincter function or control b. a gas accumulation in the lumen of the intestine; stretches and distends (a common cause of abdominal fullness, pain, and cramping) 29. increased venous pressure from straining and defecation, pregnancy, heart failure, and chronic liver disease 30. artificial opening in the abdominal wall 31. surgical opening in the ileum 32. surgical opening in the colon 33. loop colostomy, end colostomy, and a double-barrel colostomy 34. a. determination of the usual elimination pattern b. client’s description of usual stool characteristics c. identification of routines followed to promote normal elimination d. assessment of the use of artificial aids at home e. presence and status of bowel diversions f. changes in appetite g. diet history h. description of daily fluid intake i. history of surgery or illness j. medication history k. emotional state l. history of exercise m. history of pain or discomfort n. social history o. mobility and dexterity 35. all 4 quadrants for contour, shape, symmetry, and skin color 36. assess bowel sounds in all 4 quadrants 37. for masses or areas of tenderness 38. detects lesions, fluid, or gas 39. or guaiac test, which measures microscopic amounts of blood in feces; useful as a screening tool for colon cancer 40. a. Color: Infant: yellow; adult: brown b. Odor: Pungent; affected by food type c. Consistency: Soft, formed d. Frequency: Varies: Infant, 4 to 6 times daily (breast-fed) or 1 to 3 times daily (bottlefed); adult, daily or 2 to 3 times a week e. Amount: 150 g per day (adult) f. Shape: Resembles diameter of rectum g. Constituents: Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa, water 41. a. Plain Film of Abdomen/Kidneys, Ureter, Bladder b. Upper GI/Barium Swallow c. Upper Endoscopy d. Barium Enema e. Ultrasound f. Colonoscopy g. Flexible Sigmoidoscopy h. Computerized Tomography Scan



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i. Magnetic Resonance Imaging j. Enteroclysis 42. bowel incontinence 43. constipation 44. risk for constipation 45. perceived constipation 46. diarrhea 47. self-care deficit: toileting 48. client sets regular defecation habits 49. client is able to list proper fluid and food intake needed to achieve elimination 50. client implements a regular exercise program 51. client reports daily passage of soft, formed brown stool 52. client does not report any discomfort associated with defecation 53. a. sitting position b. positioning on bedpan c. privacy d. medications 54. have the short-term action of emptying the bowel (bulk forming, emollient or wetting, saline, stimulant, lubricant) 55. Antidiarrheal opiate agents decrease intestinal muscle tone to slow passage of feces. 56. temporary relief of constipation, emptying the bowel before diagnostic tests, and bowel training 57. include tap water, normal saline, soapsuds solution, and low-volume hypertonic saline 58. is hypotonic and exerts a lower osmotic pressure than fluid in interstitial spaces 59. safest solution; it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel 60. exert osmotic pressure that pulls out of interstitial spaces; contraindicated in clients who are dehydrated and in young infants 61. creates the effect of interstitial irritation to stimulate peristalsis 62. lubricate the rectum and the colon and make the feces softer and easier to pass 63. provide relief from gaseous distention; improve the ability to pass flatus 64. that the enema is repeated until the client passes fluid that is clear and contains no fecal material 65. can cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which results in a reflex slowing of the heart rate 66. a. Decompression b. Enteral Feeding c. Compression d. Lavage 67. assess the condition of the nares and mucosa for inflammation and excoriation, frequent changing of the tape and lubrication of the nares, frequent mouth care 68. assessing the normal elimination pattern and recording times when the client is incontinent 69. incorporating principles of gerontologic nursing when providing bowel training programs for older adults 70. choosing a time in the client’s pattern to initiate defection-control measures



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71. giving stool softeners orally every day or a cathartic at least a half an hour before the selected defecation time 72. offering a hot drink or fruit juice before the defecation time 73. assisting the client to the toilet at the designated time 74. avoiding medications that increase constipation 75. providing privacy and setting a time limit for defecation 76. instruct the client to lean forward at the hip when on the toilet, to apply manual pressure with the hands over the abdomen, and to bear down but not strain to stimulate colon emptying 77. able to have regular, pain-free defecation of soft, formed stool 78. 4. Reabsorption in the small intestine is very efficient. 79. 1. See Box 46-5 for rationale. 80. 1. An infant’s stool is yellow, and adult stool is brown. 81. 2. In a supine position, it is impossible to contract the muscles used during defecation; raising the HOB assists the client to a more normal sitting position, enhancing that ability to defecate. 82. 3. correct volume for a school-aged child 83. Javier, a home care nurse, is visiting Larry at his home on one of the local cattle ranches. Larry lives 20 miles from town. He is 22 years old and had surgery 6 days ago for repair of a badly broken right leg, from being thrown from a horse. Larry also tells Javier that he “just doesn’t feel good.” His past history includes a trauma abdominal surgery repair after being struck by a bull’s horns last summer. The nurse asks Larry about his recent bowel elimination patterns over the last 5 days. Larry tells Javier that he has not had a bowel movement since he left the hospital 4 days ago and that he feels like his abdomen is tight and sore. The nurse reviews dietary intake over last da y. Diet included eggs, bacon, and toast for breaksfast; soup for lunch; and chicken, rice, and corn for dinner. He drinks about six cups of coffee each day; no water, but he will drink a Coke. The nurse asks about any nausea or vomiting, which Larry denies. The nurse then auscultates client’s abdomen and finds decreased bowel sounds throughout all four abdominal quadrants. On palpation, left lower quadrant is tender and firm. Larry states, “It really hurts.” The goals are that the client will establish normal defecation, will voice relief from constipation, and will identify measures that will prevent constipation. The goals will be accomplished by Javier by encouraging fluid intake of appropriate fluids, fruit juice, and water; encouraging activity within the limits of client’s mobility regimen; adding 20g/day of wheat bran to diet; providing stool softeners or laxatives a s ordered; and providing privacy when defecating.



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Chapter 47: Mobility and Immobility

1. c 2. e 3. d 4. f 5. b 6. a 7. r 8. g 9. h 10. e 11. s 12. f 13. l 14. k 15. n 16. q 17. c 18. o 19. b 20. j 21. m 22. p 23. a 24. I 25. d 26. a. torticollis: Inclining of head to affected side, in which sternocleidomastoid muscle is contracted b. lordosis: Exaggeration of anterior convex curve of lumbar spine c. kyphosis: Increased convexity in curvature of thoracic spine d. scoliosis: Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders e. congenital hip dysplasia: Hip instability with limited abduction of hips and, occasionally, adduction contractures (head of femur doe s not articulate with acetabulum because of abnormal shallowness of acetabulum) f. knock knee: Legs curved inward so that knees come together as person walks g. bowlegs: One or both legs bent outward at knee, which is normal until 2 to 3 years of age h. clubfoot: 95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus) i. footdrop: Inability to dorsiflex and invert foot because of peroneal nerve damage j. pigeon-toes: Internal rotation of forefoot or entire foot; common in infants 27. impaired body alignment, balance, and mobility 28. bruises, contusions, sprains, and fractures



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29. to the person’s ability to move about freely 30. inability to move freely 31. a. Reducing physical activity and the oxygen needs of the body b. Reducing pain, including postoperative pain or after acute injury, to the lower back c. Allowing ill or debilitated clients to rest d. Allowing exhausted clients the opportunity for uninterrupted rest 32. decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances 33. a. collapse of alveoli b. inflammation of the lung from stasis or pooling of secretions 34. a. increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP b. accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel 35. a. loss of endurance, strength, and muscle mass and decreased stability and balance b. impaired calcium metabolism c. impaired joint mobility d. osteoporosis e. joint contractures f. footdrop 36. a. urinary stasis (renal pelvis fills before urine enters the ureters) b. renal calculi (calcium stones that lodge in the renal pelvis) 37. a. pressure ulcers (impairment of the skin as a result of prolonged ischemia in tissues) 38. a. emotional and behavioral responses b. sensory alterations c. changes in coping 39. is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse 40. particular manner or style of walking 41. physical activity for conditioning the body, improving health, and maintaining fitness 42. identifies deviations, learning needs, identifies trauma, risk factors 43. ineffective airway clearance 44. ineffective individual coping 45. risk for injury 46. impaired skin integrity 47. disturbed sleep pattern 48. social isolation 49. impaired urinary elimination 50. a. skin color and temperature return to normal baseline within 20 minutes of position change b. changes position at least every 2 hours 51. a. prevention of work-related injury b. fall prevention measures c. exercise d. early detection of scoliosis 52. a. a high caloric diet b. vitamin B and C supplements 53. a. deep breathe and cough every 1-2 hours b. CPT c. ensure intake of 2000 mL of fluid per day 54. a. reduce orthostatic hypotension – early mobilization b. reduce cardiac workload – avoid Valsalva movements c. prevent thrombus formation – prophylaxis (heparin, SCDs, and TEDs) 55. a. perform active and passive ROM exercises b. CPM machines 56. a. positioning and skin care b. use of therapeutic devices to relieve pressure 57. a. well-hydrated b. prevent urinary stasis and calculi and infections



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58. a. anticipate change in the client’s status and provide routine and informal socialization b. stimuli to maintain client’s orientation 59. a. prevents external rotation of the hips when the client is in supine position b. maintain the thumb in slight adduction and in opposition to the fingers c. allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises 60. HOB elevated 45-60 degrees and the knees are slightly elevated 61. rest on their backs; all the body parts are in relation to each other 62. lies face or chest down 63. the client rests on the side with body weight on the dependent hip and shoulder 64. client places the weight on the anterior ileum humerus and clavicle 65. are activities beyond ADLs that are necessary to be independent in society 66. Always stand on the client’s affected side and support the client by using a gait belt. 67. the client’s ability to maintain or improve body alignment, improve mobility; protect the client from the hazards of immobility 68. 1. footdrop. Allowing the foot to be dorsiflexed at the ankles prevents this. 69. 3. due to immobility causing decreased lung elastic recoiling and secretions accumulating in portions of the lungs 70. 4. need to measure bilateral calf circumference 71. 4. this technique produces a forceful, productive cough without excessive fatigue 72. Ms. Barbara Adams, an 84-year-old client, has been admitted to a skilled care unit for rehabilitation after a total hip replacement (THR) for osteoarthritis. She has a history of smoking and hypertension. She experiences “aches” and “stiffness” in her joints, especially in her knees and fingers. The wound is clean, dry, and intact. Staples will be removed in 2 days. She states, “I am afraid I am going to fall.” She takes pain medication to help her sleep during the night but does not need any during the day. She is to start physical therapy tomorrow. Ms. Adams’ pain level, as reported to the nurse, is rated as a 2 on a scale of 0 to 10 at rest, but it increases to an 8 with activity. The nurse assesses Ms. Adams’ ability to transfer and finds that she is not able to transfer with help from chair to bed. When the nurse asks Ms. Adams how her surgery has affected he r mobility, she responds that she does not like to get out of bed and that she needs help to get dressed in the morning. In order to adjust Ms. Adams’ care, the nurse instructs Ms. Adams about safe transfer and ambulation techniques in an environment with few distractions. In addition, the nurse will provide written materials that reinforce verbal instructions. The nurse understands that providing instruction in a quiet environment and giving written instructions in large, easy-toread print enhances learning in the older client. The nurse will also establish realistic increments for transferring and increasing distance for ambulation because gradually increasing physical activity and setting realistic goals for ambulation encourages activity in older adults. The nurse will perform a comprehensive assessment of pain including location, characteristics, onset/duration, frequency, quality, severity and precipitating factors. A thorough assessment is essential in managing pain in o lder adults. The nurse will be able to determine if pain is being caused by a chronic condition (e.g., osteoarthritis) or by the surgery. The nurse can encourage Ms. Adams to use nonpharmacological techniques (e.g., guided imagery) before, after and, if possible, during p ainful activities to decrease pain and



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increase mobility. The nurse can also encourage Ms. Adams to use adequate pain medication, as aggressive pain management is needed following surgery to decrease the effects of pain and increase mobility in the elderly client.



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Chapter 48: Skin Integrity and Wound Care

1. 2. 3. 4. 5. 6. 7. 8.

e f a b d c a. pressure intensity b. pressure duration c. tissue tolerance a. impaired sensory perception b. impaired mobility c. alteration in level of consciousness d. shear e. friction f. moisture 9. I – intact skin with non-blanchable redness of a localized area over a bony prominence II – partial-thickness skin loss involving epidermis, dermis, or both III – full- thickness with tissue loss IV – full-thickness tissue loss with exposed bone, tendon, or muscle 10. red, moist tissue comprised of new blood vessels, which indicates wound healing 11. stringy substance attached to wound bed that is soft, yellow, or white tissue 12. black or brown necrotic tissue 13. describes the amount, color, consistency, and odor of wound drainage 14. wound that is closed by epithelialization with minimal scar formation 15. wound edges are not approximated; the wound heals by granulation tissue formation, wound contract, and epithilialization 16. Wound is left open for several days; then the wounds are approximated. 17. inflammatory response, epithelial proliferation (reproduction), and migration with reestablishment of the epidermal layers 18. begins minutes after the injury and continues for up to 3 days. Hemostasis; injured blood vessels constrict and platelets gather to stop bleeding, clots form a fibrin matrix. Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues. 19. new blood vessels as reconstruction progresses, begins, and lasts 3-24 days. Filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization 20. Maturation, the final stage, may take up to a year; the collagen scar continues to reorganize and gain strength for several months. 21. occurs after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (internal or external) 22. Second most common nosocomial infection; purulent material drains from the wound (yellow, green, or brown, depending on the organism) 23. a partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity 24. total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair 25. abnormal; passage between 2 organs or between an organ and the outside of the body 26. a. Norton scale b. Braden scale 27. a. nutrition b. tissue perfusion c. infection d. age e. wound healing 28. potential effects of impaired mobility; muscle tone and strength



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29. malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of IDW, or a decrease of 10 lbs in a brief period 30. Continuous exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases risk for breakdown. 31. Adequate pain control and client comfort will increase mobility, which in turn reduces risk. 32. a. abrasion – is superficial with little bleeding and is considered a partial-thickness wound b. laceration – sometimes bleeds more profusely depending on depth and location (greater than 5 cm or 2.5 cm in depth) c. puncture – bleeds in relation to the depth and size, with high risk of internal bleeding and infection 33. whether the wound edges are closed, the condition of tissue at the wound base; look for complications and skin coloration 34. amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound 35. Observe the security of the drain and its location with respect to the wound, character of the drainage; measure the amount. 36. Surgical wounds are closed with staples, sutures, or wound closures. 37. risk for infection 38. imbalanced nutrition: less than body requirements 39. acute or chronic pain 40. impaired skin integrity 41. impaired physical mobility 42. risk for impaired skin integrity 43. ineffective tissue perfusion 44. impaired tissue integrity 45. a. higher percentage of granulation tissue in the wound base b. no further skin breakdown in any body location c. an increase in the caloric intake by 10% 46. decreased sensory perception: Assess pressure points for signs of nonblanching reactive hyperemia. Provide pressure redistribution surface. moisture: Assess need for incontinence management. Following each incontinent episode, cleanse area with no-rinse perineal cleanser and protect skin with a moisture barrier ointment. friction and shear : Reposition client using a drawsheet and lifting off of surface. Provide a trapeze to facilitate movement. Position client at a 30-degree lateral turn and limit head elevation to 30 degrees. decreased activity/mobility: Establish and post individualized turning schedule. poor nutrition: Provide adequate nutritional and fluid intake; assist with intake as necessary. Consult dietitian for nutritional evaluation. 47. removal of nonviable necrotic tissue to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base necessary for healing 48. a. mechanical b. autolytic c. chemical d. sharp/surgical 49. control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma, for 24-48 hours 50. gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue)



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51. applying sterile or clean dressings and immobilizing the body part 52. a. protects a wound from microorganism contamination b. aids in hemostasis c. promotes healing by absorbing drainage and debriding a wound d. supports or splints the wound site e. protects the client from seeing the wound f. promotes thermal insulation of the wound surface g. provides a moist environment 53. a. use a dressing that will continuously provide a moist environment b. perform wound care using topical dressings as determined by assessment c. choose a dressing that keeps the surrounding skin dry d. choose a dressing that controls exudates e. consider caregiver time, availability, and cost f. eliminate wound dead space by loosely filling all cavities with dressing material 54. a, adheres to undamaged skin b. serves as a barrier to external fluids and bacteria but allows the wound surface to breathe c. promotes a moist environment d. can be removed without damaging underlying tissues e. permits viewing 55. a. absorbs drainage through the use of exudate absorbers b. maintains wound moisture c. slowly liquefies necrotic debris d. impermeable to bacteria e. selfadhesive and molds well f. acts as a preventative dressing for high-risk friction areas g. may be left in place for 3-5 days, minimizing skin trauma and disruption of healing 56. a. soothing and reduces pain b. provides a moist environment, debrides the wound d. does not adhere to the wound base and is easy to remove 57. a. assessment of the skin beneath the tape b. performing thorough hand hygiene before and after wound care c. wear sterile gloves d. removing or changing dressings over closed wounds when they become wet or if the client has signs and symptoms of infection 58. assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and in contact with all of the wound surface; do not pack tightly (overpacking causes pressure); do not overlap the wound edges (maceration of the tissue) 59. applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintains a moist environment 60. a. cleanse in a direction from the least contaminated area to the surrounding skin b. use gentle friction when applying solutions locally to the skin c. when irrigating, allow the solution to flow from the least to most con taminated area 61. use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. Never occlude a wound opening with a syringe. 62. portable units that connect tubular drains lying within a wound bed and exert a safe, constant low pressure vacuum to remove and collect drainage 63. a. creating pressure over a body part b. immobilizing a body part c. supporting a wound d. reducing or preventing edema e. securing a splint f. securing dressings 64. a. inspecting the skin for abrasions, edema, discoloration, or exposed wound edges b. covering exposed wounds or open abrasions with a sterile dressing c. assessing the condition of underlying dressings and changing if soiled d. assessing the skin for underlying areas that will be distal to the ban dage for signs of circulatory impairment 65. a. heat – improves blood flow to an injured part; if applied > 1 hour the body reduces blood flow by reflex vasoconstriction to control heat loss from the area b. cold – diminishes swelling and pain, prolonged results in reflex vasodilation 66. A person is better able to tolerate short exposure to temperature extremes.



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67. more sensitive to temperature temperature variations – neck, inner aspect of the wrist and forearm, forearm, and perineal region 68. Exposed skin layers are more sensitive sensitive to temperature temperature variations. 69. The body responds best to minor temperature adjustments. 70. A person has less tolerance tolerance to temperature changes to which a large large area of the body is exposed. 71. Tolerance to temperature temperature variations changes with age. 72. physical conditions that reduce the the reception or perception of sensory stimuli; tolerance to temperature extremes is high but the risk is also 73. Uneven temperature distribution distribution suggests that the equipment is functioning improperly. 74. very young or older clients: Thinner skin layers in children increase risk of burns. Older clients have reduced sensitivity to pain. open wounds: Subcutaneous and visceral tissues are more sensitive to temperature variations. They also contain no temperature and fewer pain receptors. areas of edema: Reduced sensation to temperature stimuli occurs because of thickening of skin layers from fluid buildup or scar formation. PVD: Body’s extremities are less sensitive to temperature and pain stimuli because of circulatory impairment and local tissue injury. Cold application further compromises blood flow. Confusion: Perception of sensory or painful stimuli is reduced. Spinal cord injury: Alterations in nerve pathways prevent reception of sensory or painful stimuli. Abscessed tooth: Infection is highly localized. Application of heat causes rupture with spread of microorganisms systematically. 75. improve circulation, relieve relieve edema, and promote consolidation of pus and drainage 76. promotes circulation, lessens edema, increases muscle relaxation, and provides a means to debride wounds and apply medicated solutions 77. the pelvic pelvic area is immersed immersed in warm fluid 78. used for treating treating muscle sprains and inflammation and edema 79. disposable hot packs that apply warm, dry heat to an area 80. relieves relieves inflammation inflammation and swelling swelling 81. immersing immersing a body part for 20 minutes minutes 82. used for muscle sprain, localized hemorrhage, hemorrhage, or hematoma 83. a. Was the etiology of the skin impairment addressed? B. Was wound healing supported by providing the wound base with a moist, protected environment? C. Were issues such as nutrition assessed and a plan of care developed ? 84. 3. is the force exerted parallel parallel to the skin resulting resulting from both gravity pushing down on the body and resistance between the client and the surface 85. 1. Perception, moisture, activity, activity, mobility, nutrition, nutrition, friction, and shear are the the subscales . 86. 3. Recommended protein intake for adults is 0.8g/kg; a higher intake of up to 1.8g/kg/day is necessary for healing. 87. 2. See Table 48-9 for choice and rationale rationale for dressings for for ulcer stages. 88.



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Mrs. Stein, a 76-year-old, is 7 days postoperative for a total hip replacement. She developed redness and oozing of foul-smelling, tan-colored drainage from the hip incision on postoperative day four. Significant medical history includes arthritis and mild hypertension. Because of surgical pain at the incision site, she did not easily transfer from her bed to the chair. Now on day seven, she notes some pain at the incision and complains of a painful, burning sensation in the sacral region. She is continent of urine and stool but continues c ontinues to “scoot” over to the side of the bed when preparing for bed-to-chair bed -to-chair transfers. The nurse obtains an oral temperature and determines that it is elevated. The nurse then asks Ms. Stein how the surgical site limits her mobility, to which she relates that her h ip always aches and the pain increases upon movement. She tells the nurse that she prefers to keep the hip immobile to keep the pain level down. Position of comfort is supine, and Mrs. Stein resists position changes. The nurse performs a total bo dy skin assessment, paying special attention to the sacral area. The nurse n urse notes that the client has reactive hyperemia around the sacral area; this area does not blanch upon palpation. There is a partial-thickness ulcer directly over the sacral area. No other areas are open, with the exception of the surgical site. Key areas covered during the assessment included: Sensation, Mobility, Continence, Presence of Wound.



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Chapter 49: Sensory Alterations

1. c 2. f 3. d 4. b 5. a 6. e 7. c 8. f 9. h 10. j 11. l 12. d 13. I 14. k 15. b 16. g 17. a 18. e 19. a. sensory input (deficit (deficit from visual or hearing hearing loss) b. elimination elimination of patterns or meaning from input (exposure to strange environment) c. restrictive environments that produce monotony and boredom 20. cognitive: Reduced capacity to learn; Inability to think or p roblem-solve; Poor task performance; Disorientation; Bizarre thinking; Increased need for socialization, altered mechanisms of attention affective: Boredom; Restlessness; Increased anxiety; Emotional liability; Panic; Increased need for physical stimulation perceptual: Changes in visual/motor coordination; Reduced color p erception; Less tactile accuracy; Ability to perceive size and shape; Chan ges in spatial and time judgment 21. when a person receives multiple multiple sensory stimuli and cannot perceptually perceptually disregard or selectively ignore some stimuli 22. age, meaningful stimuli, amount of stimuli, social interaction, interaction, environmental factors, cultural factors 23. older adults due to normal physiological changes, individuals that live live in confined environments, acutely ill clients 24. a. Physical Physical appearance appearance and behavior: behavior: Motor Motor activity, activity, posture, posture, facial facial expressio expression, n, hygiene hygiene b. Cognitive Cognitive ability: ability: Level of consciousn consciousness, ess, abstract abstract reasoning, reasoning, calculati calculation, on, attention, attention, judgment; Ability to carry on conversation and ability to read, write, and copy figure; Recent and remote memory c. Emotional Emotional stability stability:: Agitation, Agitation, euphoria, euphoria, irritabi irritability lity,, hopelessness, hopelessness, or wide wide mood swings; Auditory, visual, or tactile hallucinations, illusions, delusions 25. Sense Assessment Child Behavior Adult Behavior



Vision

Technique Ask client to read newspaper, magazine, or lettering on menu.

Ask client to identify colors on color chart or crayons.

Hearing

Observe client performing ADLs. Assess client’s hearing acuity and history of tinnitus. Observe client conversing with others. Inspect ear canal for hardened cerumen. Observe client behaviors in a group.

Touch

Check client’s ability to discriminate between sharp and dull stimuli. Assess whether client is able to distinguish objects (coin or safety pin) in the hand with eyes closed.

Smell

Ask whether client feels unusual sensations. Have client close eyes and identify several nonirritating odors (e.g., coffee,

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Self-stimulation, including eye rubbing, body rocking, sniffing or smelling, arm twirling; hitching (using legs to propel while in sitting position) instead of crawling

Poor coordination, squinting, underreaching or overreaching for objects, persistent repositioning of objects, impaired night vision, accidental falls

Frightened when unfamiliar people approach, no reflex or purposeful response to sounds, failure to be awakened by loud noise, slow or absent development of speech, greater response to movement than to sound, avoidance of social interaction with other children

Blank looks, decreased attention span, lack of reaction to loud noises, increased volume of speech, positioning of head toward sound, smiling and nodding of head in approval when someone speaks, use of other means of communication such as lip-reading or writing, complaints of ringing in ears Clumsiness, over reaction or under reaction to painful stimulus, failure to respond when touched, avoidance of touch, sensation of pins and needles, numbness

Inability to perform developmental tasks related to grasping objects or drawing, repeated injury from handling of harmful objects (e.g., hot stove, sharp knife)

Unable to identify object placed in hand

Difficult to assess until child is 6 or 7 years old, difficulty discriminating

Failure to react to noxious or strong odor, increased body odor, increased



Taste

Position sense

vanilla). Ask client to sample and distinguish different tastes (e.g., lemon, sugar, salt). (Have client drink or sip water and wait 1 minute between each taste.) Observe client in the environment. The blind or severely visually impaired often touch the boundaries or objects to gain a sense of their surroundings.

160 noxious odors Inability to tell whether food is salty or sweet, possible ingestion of strangetasting things

sensitivity to odors Change in appetite, excessive use of seasoning and sugar, complaints about taste of food, weight change

Clumsiness, disorientation, accidental falls

Clumsiness, disorientation, accidental falls

26. a. uneven, cracked walkways leading to doors b. doormats with slippery backing c. extension and phone cords in walkways d. loose area rugs and runners e. bathrooms without shower or tub grab bars f. unmarked water faucets g. slippery bathroom floors h. absence of smoke detectors i. unlit stairways, lack of railings j. cluttered floors k. kitchen equipment with hard-to-read settings 27. a. (motor) inability to name common objects or to express simple ideas in words or writing b. (sensory) the inability to understand written or spoken language 28. impaired adjustment 29. impaired verbal communication 30. risk for injury 31. impaired physical mobility 32. self-care deficit 33. situational low self-esteem 34. disturbed sensory perception 35. social isolation 36. disturbed thought processes 37. a. use communication techniques for improved reception of messages b. demonstrate technique for cleansing hearing aid within 1 week c. use proper communication skills to send and receive messages d. self-report improved hearing acuity 38. a. screening for rubella or syphilis in women who are considering pregnancy b. advocate adequate prenatal care to prevent premature birth c. periodic screening of children, especially newborns through preschoolers, for congenital blindness and visual impairment caused by refractive error and strabismus 39. refractive error such as nearsightedness 40. a. family history b. prenatal infection c. low birth weight d. chronic ear infection e. Down syndrome 41. Senses Physiological Change Interventions


Study Guide Answer Key Vision

161 Presbyopia: A gradual Assess for the presence of decline in the ability of social networks and the lens to accommodate supportive relationships. or to focus on close Complete a thorough health objects. Individual is history and physical unable to see near objects assessment to identify health clearly. problems that complicate life with visual impairment. Cataract: Cloudy or opaque Encourage client to discuss areas in part of the lens or what goals are important to the entire lens that him or her. interfere with passage of Provide factual information light through the lens, about the disease and answer causing problems with questions truthfully. glare and blurred vision. Assist with identification of Cataracts usually develop creative strategies to promote gradually, without pain, self-care. redness, or tearing in the Explore the client’s ability to eye. cope with the loss of vision Dry eyes: Result when tear and encourage expression of glands produce too few feelings (e.g., denial, anger, tears, resulting in itching, hopelessness). burning, or even reduced vision. Glaucoma: A slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness, and a halo effect around lights, if left untreated. Diabetic retinopathy: Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss due to hemorrhage and macular edema. Macular degeneration: Condition in which the



162 macula (specialized portion of the retina responsible for central vision) loses its ability to function efficiently. First signs include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines. Presbycusis: A common progressive hearing disorder in older adults.

Hearing

Cerumen accumulation: Buildup of earwax in the external auditory canal. Cerumen becomes hard and collects in the canal and causes a conduction deafness.

Taste and smell

Xerostomia: Decrease in salivary production that leads to thicker mucus

Irrigation of the canal with two to three ounces of tepid water in a 60ml syringe (see Chapter 39) will remove cerumen and significantly improve the client’s hearing ability. The screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) is a 5-minute, 10-item questionnaire developed to assess how the individual perceives the social and emotional effects of hearing loss. Prevention involves regular immunization of children against diseases capable of causing hearing loss (e.g., rubella, mumps, and measles). Nurses who work in physicians’ offices, schools, and community clinics need to reinforce the importance of early and timely immunization. Advise pregnant women to seek early prenatal care and to undergo testing for syphilis and rubella. In all populations, use caution when administering drugs that are ototoxic. Good oral hygiene keeps the taste buds well hydrated. Well-seasoned, differently



163 and a dry mouth. Often interferes with the ability to eat and leads to appetite and nutritional problems.

textured food eaten separately heightens taste perception. Flavored vinegar or lemon juice adds tartness to food. Always ask the client what foods are most appealing. Improvement in taste perception improves food intake and appetite as well. Stimulation of the sense of smell with aromas such as brewed coffee, cooked garlic, and baked bread heightens taste sensation. The client needs to avoid blending or mixing foods, because these actions make it difficult to identify tastes. Older persons need to chew food thoroughly to allow more food to contact remaining taste buds.

Touch

With aging, there are decreased skin receptors. Clients with reduced tactile sensation usually have the impairment over a limited portion of their bodies.

You improve smell by strengthening pleasant olfactory stimulation. Make a client’s environment more pleasant with smells such as cologne, mild room deodorizers, fragrant flowers, and sachets. The removal of unpleasant odors (e.g., bedpans, soiled dressings) will also improve the quality of a client’s environment. Providing touch therapy stimulates existing function. If the client is willing to be touched, hair brushing and combing, a back rub, and touching of the arms or shoulders are ways of increasing tactile contact. When sensation is reduced, a firm pressure is often necessary for the client to feel the nurse’s hand. Turning and



164 repositioning will also improve the quality of tactile sensation. When performing invasive procedures, it is important to use touch by holding the client’s hands and keeping them warm and dry.

Trachea

If a client is overly sensitive to tactile stimuli (hyperesthesia), minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with the client and protecting the skin from exposure to irritants are helpful measures. In hospitalized clients The client is sometimes needing an artificial airway, completely alert and able to oftentimes an endotracheal hear and see the nurse tube is inserted into the normally. Giving the client oropharynx and down time to convey any needs or through the vocal cords of the requests is very important. larynx into the upper Use creative communication bronchus. The placement of techniques (e.g., a the tube prevents a client communication board or a from speaking. laptop computer) to foster and strengthen the client’s interactions with health care personnel, family, and friends.

42. clients with aphasia – Listen to the client and wait for the client to communicate. Do not shout or speak loudly (hearing loss is not the problem). If the client has problems with comprehension, use simple, short questions and facial gestures to give additional clues. Speak of things familiar and of interest to the client. If the client has problems speaking, ask questions that require simple yes or no answers or blinking of the eyes. Offer pictures or a communication board so that the client can point. Give the client time to understand; be calm and patient; do not pressure or tire the client. Avoid patronizing and childish phrases. clients with an artificial airway – Use pictures, objects, or word cards so that the client can point. Offer a pad and pencil or Magic Slate for the client to write messages. Do not shout or speak loudly. Give the client time to write messages, because these clients become easily fatigued. Provide an artificial voice box (vibrator) for the client with a laryngectomy to use to speak. clients with a hearing impairment –Get the client’s attention. Do not startle the client when entering the room. Do not approach a client from behind. Be sure the client knows that you



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wish to speak. Face the client and stand or sit on the same level. Be sure your face and lips are illuminated to promote lip-reading. Keep hand s away from mouth. Be sure that clients keep eye glasses clean so that they are able to see your gestures and face. If the client wears a hearing aid, make sure it is in place and working. Speak slowly and articulate clearly. Older adults often take longer to process verbal messages. Use a normal tone of voice and inflections of speech. Do not speak with something in your mouth. When you are not understood, rephrase rather than repeat the conversation. Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Loud sounds are usually higher pitched and often impede hearing by accentuating vowel sounds and concealing consonants. If you need to raise your voice, speak in lower tones. Talk toward the client’s best or normal ear. Use written information to enhance the spoken word. Do not restrict a deaf client’s hands. Never have IV lines in both of the client’s hands if the preferred method of communication is sign language. Avoid eating, chewing, or smoking while speaking. Avoid speaking from another room or while walking away. 43. a. orientation to the environment – name tags are visible, address the client by name, explain to the client any transfers, note physical boun daries b. communication – depending on the type of aphasia (Box 49-9) c. control sensory stimuli – prevent overload by organizing client’s care with periods of rest; control extraneous noise d. safety measures – help with ambulation, sighted guide, frequent repositioning 44. a. Spend time with a person in silence or conversation. b. Use physical contact (holding a hand, embracing a shoulder) to convey caring. c. Help recommend alterations in living arrangements if physical isolation is a factor. d. Assist older adults in keeping in contact with people important to them. e. Help obtain information about mutual help groups. f. Arrange for security escort services as needed. g. Bring a pet that is easy to care for into the home. h. Link a person with religious organizations attuned to the social needs of older adults. 45. the nature of a client’s alterations influence how the nurse would evaluate the outcome of care; if the expected outcomes have not been achieved, there needs to be a change in the interventions or an alteration in the client’s environment; also ne ed to evaluate the integrity of the sensory organs and the client’s ability to perceive stimuli 46. 1. due to sensory deprivation related to restrictive environment of the hospital 47. 4. the presence or absence of meaningful stimuli (constant TV) influences alertness and the ability to participate in care 48. 3. Priorities need to be set in regard to the type and extent of the sensory alteration, and safety is always a top priority. 49. 4. motor type of aphasia 50. Judy was released from the hospital in good h ealth one week after admission. Following the recommendation of her health care provider, she regularly attends a heart-failure support group. She has asked the nurse to speak with the heart-failure support group regarding agerelated visual changes, as well as signs and symptoms that may indicate problems. Some of the selected strategies to assist Judy in remaining functional in h er home would include removing any potential safety hazards (e.g., uneven, cracked walkways, slippery doormats, rugs or other floor surfaces, extension or phone cords in the main route of walking



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traffic, bathrooms without shower or tub grab-bars, poorly lit areas, absence o f smoke detectors, clutter in the home, kitchen equipment with hard-to-read settings). The nurse will assist Judy in planning transportation to and from social activities and her supp ort group. The nurse will also involve family in assisting Judy to adjust to her limitations and referring Judy to the appropriate health care, professional, and community agencies for assistance.



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Chapter 50: Care of Surgical Clients

1. preoperative (before), intraoperative (during), postoperative (after surgery) 2. a. anesthetic drugs that metabolize rapidly with few after-effects allow for shorter operative times and faster recovery time b. offers cost savings by e liminating the need for hospital stay c. use of laparoscopic procedures instead of traditional surgical procedures decreases the length of surgery, hospitalization, and costs 3. d 4. h 5. j 6. c 7. g 8. I 9. b 10. l 11. f 12. k 13. a 14. e 15. thrombocytopenia: Increase risk of hemorrhaging during and after surgery. diabetes mellitus: Increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment (Furnary and others 2003). Stress of surgery often causes increases in blood glucose levels. heart disease: Stress of surgery causes increased demands on myocardium to maintain cardiac output. General anesthetic agents depress cardiac function. obstructive sleep apnea: Administration of opioids increases risk of airway obstruction postoperatively. Clients will desaturate as revealed by drop in O2 saturation by pulse oximetry. upper respiratory infection: Increases risk of respiratory complications during anesthesia (e.g., pneumonia and spasm of laryngeal muscles). liver disease: Alters metabolism and elimination of drugs administered during surgery and impairs wound healing and clotting time because of alterations in protein metabolism. fever: Predisposes client to fluid and electrolyte imbalances and may indicate und erlying infection. emphysema: Reduces client’s means to compensate for acid-base alterations (see Chapter 41). Anesthetic agents reduce respiratory function, increasing risk for severe hypoventilation. AIDS: Increases risk of infection and delayed wound healing after surgery. Abuse of street drugs: Persons abusing drugs sometimes have underlying disease (HIV/hepatitis), which affects healing. Chronic pain: Regular use of pain medications often results in higher tolerance. Increased doses of analgesics are sometimes necessary to achieve po stoperative pain control. 16. a. poor tolerance to anesthesia b. negative nitrogen balance from the lack of protein c. delayed clotting mechanisms d. infection e. poo r wound healing f. multiple organ failure



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17. a difficulty resuming activity after surgery b. reduced ventilatory and cardiac function c. poor wound healing and wound infection d. high risk of dehiscence and evisceration 18. cardiovascular system: Degenerative change in myocardium and valves: Reduced cardiac reserve • Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation • to heart: Alterations predispose client to postoperative hemorrhage and rise in systolic and diastolic blood pressure. Increase in calcium and cholesterol deposits within small arteries; thickened arterial • walls: Predispose client to clot formation in lower extremities integumentary system: Decreased subcutaneous tissue and increased fragility of skin: Prone to p ressure ulcers • and skin tears pulmonary system: Rib cage stiffened and reduced in size renal system: Reduced vital capacity • Reduced range of movement in diaphragm: Greater residual capacity (volume of air is • left in lung after normal breath) increases, reducing amount of new air brought into lungs with each inspiration Stiffened lung tissue and enlarged air spaces: Alteration reduces blood oxygenation. • neurological system: Sensory losses, including reduced tactile sense and increased pain tolerance: Decreased • ability to respond to early warning signs of surgical complications Decreased reaction time: Confusion after anesthesia • metabolic system: Lower basal metabolic rate: Reduced total oxygen consumption • Reduced number of red blood cells and hemoglobin levels: Ability to carry adequate • oxygen to tissues is reduced. Change in total amounts of body potassium and water volume: Greater risk for fluid or • electrolyte imbalance occurs. Impaired thermoregulatory mechanisms: Cold operating rooms; exposure of body parts • during procedure, IV fluids, medications 19. Antibiotics: Antibiotics potentiate (enhance action) of anesthetic agents. If taken within 2 weeks before surgery, aminoglycosides (gentamycin, tobramycin, neomycin) may cause mild respiratory depression from depressed neuromuscular transmission. Antidysrhythmias: Antidysrhythmics (for example, beta blockers such as metoprolol [Lopressor®]),, can reduce cardiac contractility and impair cardiac conduction during anesthesia. Anticoagulants: Anticoagulants, such as warfarin (Coumadin®), alter normal clotting factors and thus increase risk of hemorrhaging. Discontinued at least 48 hours before surgery. Aspirin is a commonly used medication that alters clotting mechanisms. Anticonvulsants: Long-term use of certain anticonvulsants (e.g., phenytoin [Dilantin®] and phenobarbital) alters metabolism of anesthetic agents.



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Antihypertensives: Antihypertensives, such as beta blockers and calcium channel blockers, interact with anesthetic agents to cause bradycardia, hypotension, and impaired circulation. They inhibit synthesis and storage of norepinephrine in sympathetic nerve endings. Corticosteroids: With prolonged use, corticosteroids, such as prednisone, cause adrenal atrophy, which reduces the body’s ability to withstand stress. Before and during surgery, dosages are often temporarily increased. Insulin: Diabetic clients’ need for insulin changes after surgery. Stress response and intravenous (IV) administration of glucose solutions often increase dosage requirements after surgery. Decreased nutritional intake often decreases dosage requirements. Diuretics: Diuretics such as furosemide (Lasix®) potentiate electrolyte imbalances (particularly potassium) after surgery. NSAIDs: NSAIDs (for example, ibuprofen) inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding. Herbal therapies: These herbal therapies have the ability to affect platelet activity and increase susceptibility to postoperative bleeding. Ginseng is reported to increase hypoglycemia with insulin therapy. 20. a. greater risk for pulmonary complication due to increased amount and thickness of mucous secretions in the lungs b. predisposes the client to adverse reactions to anesthetic agents and cross-tolerance to anesthetic agents; malnourishment also leads to delayed wound healing 21. a. family expectations for pain management following surgery b. perceived tolerance to pain c. past experiences and interventions used 22. have client identify personal strengths and weaknesses; poor self-concept hinders the ability to adapt to the stress of surgery and aggravates feelings of guilt or inadequacy 23. assess for body image alterations that clients perceive will result, taking into consideration culture, age, self-concept, and self-esteem; removal of b ody parts often leaves permanent disfigurement, alteration in body function or concern over mutilation, loss of body function 24. of feelings and self-concept reveals whether the client is able to cope with the stress of surgery, past stress management and behaviors utilized, and coping resources 25. a. general survey b. head and neck c. integument d. thorax and lungs e. heart and vascular system f. abdomen g. neurological status 26. a. CBC: Peripheral venous sample of blood may reveal infection, low blood volume, and potential for oxygenation problems. Surgeon may order blood replacement. b. Serum electrolytes: Peripheral venous sample of blood may reveal significant fluid and electrolyte imbalances preoperatively. Attention is given to Na, K, and Cl levels. IV fluid replacement may be indicated preoperatively. c. Coagulation studies: Prothrombin time (PT), International Normalized Ratio (INR), activated partial thromboplastin time (APTT), and platelet counts reveal clotting ability of blood. Reveals clients at risk for bleeding tendencies and thrombus formation. d. Serum creatinine: Ability of kidneys to excrete creatinine, by-product of muscle metabolism, assesses renal function. Elevated level can indicate renal failure.



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e. BUN: Ability of kidneys to excrete urea and nitrogen indicates renal function. BUN becomes elevated if client is dehydrated. Preoperative IV fluid replacement is often necessary. f. glucose: Finger stick or peripheral blood sample. Clients often require treatment of low or high levels preoperatively and postoperatively. 27. ineffective airway clearance 28. risk for latex allergy response 29. anxiety 30. disturbed body image 31. risk for imbalanced body temperature 32. ineffective breathing pattern 33. ineffective coping 34. fear 35. risk for deficient fluid volume 36. risk for infection 37. risk for perioperative-positioning injury 38. deficient knowledge 39. impaired physical mobility 40. nausea 41. acute pain 42. powerlessness 43. impaired skin integrity 44. disturbed sleep pattern 45. delayed surgical recovery 46. a. prevention of lung congestion and pneumonia as reasons for deep breathing and coughing exercises and incentive spirometer b. promotion of blood flow to prevent leg clots as reason for postoperative leg exercises and ambulation c. improves lung function, assists with return of bowel function, and promotes recovery 47. understands the need for a procedure, the steps involved, risks, expected results and alternative treatments 48. a. reasons for preoperative instructions and exercises b. the time of surgery c. the postoperative unit and location of the family during surgery and recovery d. discusses anticipated postoperative monitoring and therapies e. describes surgical procedures and postoperative treatment f. postoperative activity resumption g. verbalizes painrelief measures 49. a. maintenance of normal fluid and electrolyte balance b. reduction of risk of surgical wound infection c. prevention of bowel and bladder incontinence d. promotion of rest and comfort 50. a. hygiene b. hair and cosmetics c. removal of prostheses d. safeguarding valuables e. preparing the bowel and bladder f. vital signs g. documentation h. performing special procedures i. administering preoperative medications j. latex sensitivity/allergy k. eliminating the wrong site and wrong procedure surgery 51. range from urticaria and flat or raised red patches to vesicular, scaling, or bleeding eruptions; rhinitis and rhinorrhea are also common. 52. a. sphygmomanometer, stethoscope, and thermometer b. emesis basin c. clean gown d. washcloth, towel and tissues e. IV pole f. suction equipment g. oxygen equipment



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and oximetry monitor h. extra pillows for positioning i. bed pads to protect j. bed raised to stretcher height to accommodate transfer 53. a. review of the preoperative assessment, establishing and implementing the intraoperative plan of care, evaluating the care, and providing for continuity of care postoperatively b. maintains a sterile field during the surgical procedure and assists with supplies 54. a. will have intact skin and show no signs of redness b. will be free of burns at the grounding pad 55. a. anesthesia b. surgery c. positioning d. equipment use 56. Given by IV and inhalation routes through 3 phases (induction, maintenance, and emergence), resulting in an immobile, quiet client wh o does not recall the surgical procedure 57. results in loss of sensation in an area of the body via spinal, epidural, or a peripheral nerve block with no loss of consciousness 58. involves the loss of sensation at the desired site; common for minor procedures 59. routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness 60. a. recovery period b. postoperative convalescence (both vary depending on outpatient versus inpatient ) 61. maintaining airway, respiratory, circulatory, and neurological status and on managing pain 62. vital sign stability, temperature control, good ventilatory function and oxygenation status, orientation to surroundings, absence of complications, minimal pain an d nausea, controlled wound drainage, adequate output, and fluid and electrolyte balance 63. every 15 minutes, then hourly for 4 hours then every 4 hours, basing always on the frequency of assessment on the client’s current condition 64. a. history of OSA b. weak pharyngeal/laryngeal muscle tone from anesthetics c. secretions in the pharynx, bronchial tree, or trachea d. subglottic edema 65. heart rate and rhythm, BP and capillary refill, pulses, and the color and temperature of the nail beds and skin 66. hypercabia, tachypnea, tachycardia, PVCs, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity 67. a. assess the hydration status and monitor cardiac and neurological function b. monitor can compare lab values c. maintain patency of IV lines d. record accurately the I & O, daily weights 68. a. is oriented to self and the hospital b. papillary and gag reflexes, hand grips, and movement of all extremities c. client’s sensations along dermatomes d. extremity strength 69. a. indicates a drug sensitivity or allergy b. result from inappropriate positioning or restraining that injures skin layers or from a clotting disorder c. may indicate that a electrical cautery grounding pad was incorrectly placed 70. a. accumulation of gas b. internal bleeding (late) c. develops a paralytic ileus 71. a. frequency of VS assessments b. types of IV fluids and rates c. postoperative medications d. resumption of preoperative medications e. fluid and food allowed f. level of activity g. positions h. intake and output i. lab tests and x-ray studies j special directions related to drains, irrigations, and dressings



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72. a. VS return to preoperative baseline b. airway is patent, and respirations are even and unlabored c. temperature returns to baseline and remains stable d. fluid and electrolyte levels remain balanced e. returns to previous level of activity 73. encourage diaphragmatic breathing exercises every hour 74. administer CPAP or NIPPV to clients who use this modality at home 75. use incentive spirometer for maximum inspiration 76. early ambulation 77. Turn patient on their sides every 1-2 hours and to sit when possible. 78. Keep the client comfortable. 79. Encourage coughing exercises every 32 hours and maintain pain control. 80. Provide oral hygiene. 81. Initiate orotracheal ornasotracheal suction for inability to cough. 82. Administer oxygen and monitor saturation. 83. a. atelectasis: Collapse of alveoli with retained mucous secretions. Signs and symptoms include elevated respiratory rate, dyspnea, fever, crackles auscultated over involved lobes of lungs, and productive cough. Cause: Inadequate lung expansion. Anesthesia, analgesia, and immobilized position prevent full lung e xpansion. There is greater risk in clients with upper abdominal surgery who have pain during inspiration and repress deep breathing. b. pneumonia: Inflammation of alveoli. It may involve one o r several lobes of lung. Development in lower dependent lobes of lung is common in immobilized surgical client. Signs and symptoms include fever, chills, productive cough, chest pain, purulent mucus, and dyspnea. Cause: Poor lung expansion with retained secretions or aspirated secretions. Common resident bacterium in respiratory tract is Diplococcus pneumoniae, which causes most cases of pneumonia. c. hypoxemia: Inadequate concentration of oxygen in arterial blood. Signs and symptoms include restlessness, confusion, dyspnea, high or low blood pressure, tachycardia or bradycardia, diaphoresis, and cyanosis. Cause: Anesthetics and analgesics depress respirations. Increased retention of mucus with impaired ventilation occurs because of pain or poor positioning. Clients with OSA are at increased risk for hypoxemia. d. pulmonary embolism: Embolus blocking pulmonary arterial blood flow to one or more lobes of lung. Signs and symptoms include dyspnea, sudden chest pain, cyanosis, tachycardia, and drop in blood pressure. Cause: Same factors lead to formation of thrombus or embolus. Immobilized surgical client with preexisting circulatory or coagulation disorders is at risk. e. hemorrhage: Loss of large amount of blood externally or internally in short period of time. Signs and symptoms include hypotension, weak and rapid pulse, cool and clammy skin, rapid breathing, restlessness, and reduced urine output. Cause: Slipping of suture or dislodged clot at incisional site. Clients with coagulation disorders are at greater risk. f. hypovolemic shock: Inadequate perfusion of tissues and cells from loss of circulatory fluid volume. Signs and symptoms are same as for hemorrhage. Cause: In surgical client, hemorrhage usually causes hypovolemic shock.



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g. thrombophlebitis: Inflammation of vein often accompanied by clot formation. Veins in legs are most commonly affected. Signs and symptoms include swelling and inflammation of involved site and aching or cramping pain. Vein feels hard, cordlike, and sensitive to touch. Cause: Prolonged sitting or immobilization aggravates venous stasis. Trauma to vessel wall and hypercoagulability of blood increase risk of vessel inflammation. h. thrombus: Formation of clot attached to interior wall of a vein or artery, which can occlude the vessel lumen. Symptoms include localized tenderness along distribution of the venous system, swollen calf or thigh, calf swelling >3 cm compared to asymptomatic leg, pitting edema in symptomatic leg and co llateral superficial veins, and decrease in pulse below location of thrombus (if arterial). Cause: Venous stasis (see discussion of thrombophlebitis) and vessel trauma. Venous injury is common after surgery of hips and legs, abdomen, pelvis, and major vessels. Clients with pelvic and abdominal cancer or traumatic injuries to the pelvis or lower extremities are at high risk for thrombus formation. i. embolus: Piece of thrombus that has dislodged and circulates in bloodstream until it lodges in another vessel, commonly lungs, hea rt, brain, or mesentery. Cause: Thrombi form from increased coagulability of blood (e.g., polycythemia and use of birth control pills containing estrogen). j. paralytic ileus: Nonmechanical obstruction of the bowel caused by physiological, neurogenic, or chemical imbalance associated with decreased peristalsis. Common in initial hours after abdominal surgery. Cause: Handling of intestines during surgery leads to loss of peristalsis for a few hours to several days. k. abdominal distention: Retention of air within intestines and abdominal cav ity during gastrointestinal surgery. Signs and symptoms include increased abdominal girth, tympanic percussion over abdominal quadrants, client complaints of fullness and “gas pains.” Cause: Slowed peristalsis from anesthesia, bowel manipulation, or immobilization. During laparoscopic surgeries, influx of air for procedure causes distention and pain up to shoulders. l. nausea and vomiting: Symptoms of improper gastric emptying or chemical stimulation of vomiting center. Client complains of gagging or feeling full or sick to stomach. Cause: Abdominal distention, fear, severe pain, medications, eating or drinking before peristalsis returns, and initiation of gag reflex. m. urinary retention: Involuntary accumulation of urine in bladder as result of loss of muscle tone. Signs and symptoms include inability to void, restlessness, and bladder distention. It appears 6-8 hours after surgery. Cause: Effects of anesthesia and narcotic analgesics. Local manipulation of tissues surrounding bladder and edema interfere with bladder tone. Poor positioning of client impairs voiding reflexes. n. urinary tract infection: An infection of the urinary tract as a result of bacterial or yeast contamination. Signs and symptoms include dysuria, itching, abdominal pain, possible fever, cloudy urine, WBCs, and leukocyte esterase p ositive on urinalysis. Cause: Most frequently a result of catheterization of the bladder. o. wound infection: An invasion of deep or superficial wound tissues by pathogenic microorganisms; signs and symptoms include warm, red, and tender skin aroun d incision; fever and chills; purulent material exiting from drains or from separated wound edges. Infection usually appears 3-6 days after surgery. Cause: Infection is



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caused by poor aseptic technique or contaminated wound or surgical site before surgical exploration. For example, with a bowel perforation, the client is at increased risk for a wound infection because of bacterial contamination from the large intestine. p. wound dehiscence: Separation of wound edges at suture line. Signs and symptoms include increased drainage and appearance of underlying tissues. This usually occurs 6-8 days after surgery. Cause: Malnutrition, obesity, preoperative radiation to surgical site, old age, poor circulation to tissues, and unusual strain on suture line from coughing or positioning cause dehiscence. q. wound evisceration: Protrusion of internal organs and tissues through incision. Incidence usually occurs 6-8 days after surgery. Cause: Client with dehiscence is at risk for developing evisceration. r. skin breakdown: Result of pressure or shearing forces. Surgical clients are at increased risk if alterations in nutrition and circulation are present, resulting in edema and delayed healing. Cause: Prolonged periods on the OR table and in the bed postoperatively lead to pressure breakdown. Skin breakdown results from shearing during positioning on the OR table and improper pulling of the client up in bed. s. intractable pain: Pain that is not amenable to analgesics and pain-alleviating interventions. Cause: Intractable pain may be related to the wound or dressing, anxiety, or positioning. 84. encourage to perform leg exercises 85. apply elastic antiembolism stockings or pneumatic compression stockings 86. encourage early ambulation 87. avoid positioning client in a manner that interrupts blood flow to the extremities 88. administer anticoagulant drugs as ordered 89. provide adequate fluid intake orally or IV 90. incision area, drainage tubes, tight dressing or casts, muscular strains caused by positioning 91. a. maintain a gradual progression in dietary intake (clear liquids, full liquids, light diet, usual diet) b. promote ambulation and exercise c. maintain and adequate fluid intake d. stimulate the client’s appetite (remove noxious odors, positioning, desired foods, oral hygiene) e. fiber supplements, stool softeners f. provide meals when client is rested and free from pain 92. a. assume normal positioning during voiding c. check frequently for the need to void c. assess for bladder distention d. monitor I & O 93. a. provide privacy with dressing changes or inspection of the wound b. maintain client’s hygiene c. prevent drainage devices from overflowing d. pleasant environment e. offer opportunities for the client to discuss fears or concerns f. promote client’s self- concept 94. 1. Increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment 95. 1. That is a medical decision and the responsibility of the provider. 96. 3. All of the other clients are predisposed to an imbalance either to existing loses, fluid overload, or the inability to obtain po fluids. 97. 2. promotes normal venous return and circulatory blood flow 98. 2. not always a sign of hypothermia but rather a side effect of certain anesthetic agents



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99. Mrs. Campana is an 80-year-old client scheduled to be admitted in 5 days for elective bowel resection. You are the nurse in the ASC assigned to prepare Mrs. Campana for surgery. During your initial discussion with Mrs. Campana, you assess that she is alert and oriented. Mrs. Campana states that she has severely reduced visual acuity but is able to hear your questions clearly. Mrs. Campana has had previous surgery. She lives alone and has a daughter who lives out of town. When the nurse asked Mrs. Campana about previous surgeries and her experience with them, she replied, “I had surgery over 20 years ago, and I was in the hospital for 10 days. I remember having more pain than I expected.” The nurse asks Mrs. Campana what she has been told regarding her surgery to which she responds that her surgeon explained the procedure with a drawing of the bowel and the location of the part to be removed. The nurse asks Mrs. Campana what she has been told regarding preoperative preparation and what to expect postoperatively to which she states that she received information from the surgeon’s office about medicines to take the morning of surgery, her diet before surgery and when to stop eating, and whom to call for questions. She does not recall receiving information about what to expect postoperatively. Upon assessment of Mrs. Campana’s ability to read typical font type, the nurse determines that she is unable to read the font on the newspaper but that she can read the headlines with her glasses. The nurse assesses Mrs. Campana’s family/support system for preoperative and postoperative and determines that her daughter will be coming in town the day of surgery and will stay with h er for two weeks after the surgery. Preoperative teaching included providing Mrs. Campana with an audiotape program that explains preoperative and postoperative routines. An instruction booklet designed for the visually impaired was also provided. The nurse will make a follow-up call to client and her daughter encouraging them to ask questions and voice concerns and will document the education provided. The nurse understands that preadmission education often results in less teaching time and better performance of exercises on admission. Education has a beneficial effect in reducing postoperative anxiety. On admission to the hospital, the nurse demonstrates to Mrs. Campana and her daughter the performance of postoperative exercises and how to get out of bed with assistance, as demonstration is an effective method to reinforce instruction. The nurse also explains sensations to expect postoperatively (e.g., incisional pain, IV, nasogastric tube, wound ca re). Teaching about sensory aspects (what the client sees, feels, smells) needs to be structured. Reassure client that adeq uate pain management will be available. The nurse will have Mrs. Campana demonstrate postoperative exercises before surgery to assess learning and provide an opportunity to reinforce instruction. The nurse has the opportunity to correct any unrealistic expectations Mrs. Campana or daughter have regarding surgery because unrealistic expectations, when unmet, contribute to client’s anxiety. Psychological preparation for surgery reduces anxiety. The nurse asked Mrs. Campana to describe typical monitoring and care activities following surgery and documented evaluation of her understanding. Mrs. Campana is able to verbalize typical monitoring and care following surgery. She states that the booklet and audiotape were both helpful and that she has a good understanding of the typical postoperative course. The nurse observed Mrs. Campana’s demonstration of postoperative exercises. She c orrectly demonstrates leg exercises and TC & DB but is having difficulty with IS use, indicating that she needs further teaching and practice on IS use. The nurse explores with Mrs. Campana and her daughter if they have any remaining fears or concerns. Both Mrs. Campana and her


Nursing Study Guide Answer Key

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