Nursing Test 2 TCC

  1. Clients admitted into the ER may experience behavior changes due to what?
    Sensory Overload
  2. When performing a history, the nurse assesses sensory perceptions such as what?
    Mental Status
  3. Peripheral neuropathy and parestesias become the etiology for other nursing diagnoses. An example of such a diagnosis is what?
    Risk for injury
  4. Nurses can increase environmental stimuli for clietns with sensory defecit by what?
    Establishing a routine identified with each meal
  5. A client has impaired vision. An intervention to best adapt the environment to this loss includes what?
    Keeping the room pathways free of clutter.
  6. Which statement by a client with decreased hearing indicates a need for a sensory aid in the home?
    I can't hear people knocking at the door.
  7. Which statement by a hospitalized client indicates she needs further orientation to time, place, person, or situation?
    I'm tired of sitting in this train station
  8. Which client is most likely to experience sensory deprivation?
    A deaf 88-year-old single client with +4 edema who lives in an upstairs apartment
  9. Clinical manifestations of Sensory Overload
    • -C/o fatigue, sleeplessness
    • -Irritability, anxiety, and restlessness
    • -Periodic or general disorientation
    • -Reduced problem solving abiity and task performance
    • -Increased muscle tension
    • -Scattered attention and racing thoughts
  10. Clinical Manifestations of Sensory Deprivation
    • -Excessive yawning, drowsiness, and sleep
    • -Decreased attention span and problem solving, difficulty concentrating
    • -Hallucinations or delusions
    • -Apathy and emotional liability
    • -Preoccupation with somatic complaints
    • -Crying, annoyance over small matters and depression
  11. Assessment of Sensory-Perceptual Function
    • -Nursing history
    • -Mental status exam
    • -Physical exam
    • -Environment
    • -Social Support Network
    • -Identification of clients at risk
  12. Risk Factors for Sensory Deprivation
    • -Nonstimulating or monotonous environment
    • -Impaired vision or hearing
    • -Mobility restrictions
    • -Inablility to process stimuli
    • -Emotional disorders
    • -Limited social contact
  13. Risk Factors for Sensory Overload
    • -Pain or discomfort
    • -Admission to an acute care facility
    • -Monitoring in intensive care units
    • -Invasive tubes
    • -Decreased cognitive ability
  14. Orientation Strategies for Client with Acute Confusion/Delirium
    • -Wear a readable nametag
    • -Address the person by name
    • -Introduce yourself frequently
    • -Keep room well lit during waking hours
    • -Orient the client to place if indicated
    • -Identify time and place if indicated
    • -Ask the client "where are you?"
    • -Place a calendar and clock in client's room
    • -Mark holidays with ribbons, pins etc.
    • -Speak clearly and calmly, allowing time for words to be processed and for a response
    • -Encourage family to visit frequently
    • -Provide clear concise explanation of each treatment, procedure or task
  15. Olfactory
    Provide aromatic stimuli that may include client's favorites
  16. Gustatory
    • -Provide mouth care
    • -Place different tastes on tongue
  17. Kinesthetic
    • -ROM
    • -Change client's position in bed
  18. Delirium
    Characterized by a disturbance of consciousness and a change in cognition such as impaired attention span and disturbances of consciousness that develops over a short period of time.
  19. Dementia
    Develops more slowly and is characterized by multiple cognitive defecits that include impaired memory
  20. Amnestic Disorder
    Characterized by loss in both short-term memory and long-term memory, sufficient to cause some impairment in the person's functioning
  21. Depression
    • -Gradual with excerbation during crisis or stress
    • -Difficulty concentrating, forgetfulness, inattention
    • -LOC not altered
    • -Lethargy, lack of motivation, poor sleep
    • -Extreme sadness, apathy, anxiety, irritability
    • -Speech is slow, flat, and low
    • -It is reversible with proper and timely treatment
  22. Delirium can occur:
    • -More frequently in elderly
    • -Postoperative
    • -Drugs
    • -Cardiovascular disease
    • -CHF
    • -Children with fever
  23. Symptoms of Delirium
    • -Disturbance in consciousness, thinking, memory, attention, perception
    • -Develop over a short period
    • -Fluctuates during the day
    • -Progressive disorientation to time and place
  24. Common causes of Delirium
    • -Infections
    • -Postoperative states
    • -Metabolic abnormalities
    • -Hypoxic conditions
    • -Drug withdrawal
    • -Drug intoxications
    • -Polypharmacy
  25. Nursing concerns with Delirium
    • -Assisting with proper health management to eradicate the underlying cause
    • -Preventing physical harm due to confusion, agression, or electrolyte and fluid imbalance
    • -Use supportive measures to relieve distress
  26. Nursing Diagnosis Associated with Delirium
    • -Risk for injury
    • -Fluid volume defecit
    • -Acute confusion
    • -Sleep pattern disturbance
    • -Impaired verbal communication
    • -Self-care defecits
    • -Impaired social interaction
  27. Dementia
    • -Marked by progressive deterioration in intellectual functioning, memory, and ability to solve problems and learn new skills
    • -Judgement, moral and ethical behaviors decline as personality is altered
  28. Etiology of Dimentia
    • -Neurodegenerative
    • -Vascular
  29. Types of Dimentia
    • -Alzheimer's type
    • -Pick's disease
    • -Creutzfeldt-Jakob
    • -Multiinfarct
    • -Parkinson's
    • -Korsakoff's syndrome
    • -Huntington's disease
  30. Clissifications of Dimentia
    • -Primary-is not reversible, prgoressive, not secondary to any other disorder
    • -Secondary-result of some other pathological process
  31. Pseudodementia
    • -Mimics dimentia
    • -Drug toxicity
    • -Metabolic disorders
    • -Infections
    • -Nutritional deficiencies
  32. Causes of Alzheimer's
    • -Unknown
    • -Hypotheses:
    • -Neurochemical changes
    • -Genetic defects
    • -Abnormal proteins
  33. Pathological Changes due to Alzheimers
    • -Neurofibrility tangles
    • -Senile plaques
    • -Granulovascular degeneration
  34. Four Signs of Alzheimer's
    • -Aphasia: loss of language ability
    • -Apraxia: loss of purposeful movement
    • -Agnosia: loss of sensory ability to recognize objects
    • -Mnemonic disturbance: loss of memory
  35. Cognitive Assessment Tools for Alzheimer's
    • -Mini-Mental Status Examination
    • -Clock drawing test
    • -Geriatric Depression Scale
    • -Functional Assessment (Katz)
  36. Mild Alzheimer's (Stage 1)
    • -loss of short term memory
    • -Aware of problem
    • -Depression
    • -Not diagnosible
  37. Moderate Alzheimer's (Stage 2)
    • -Progressive memory loss
    • -Withdrawn from social activities
    • -Declines in ADL's
    • -Depression increasingly common
    • -Problems intensified when stressed, fatigued, or out of own environment
    • -Needs in home assistance or day care
  38. Severe Alzheimer's (Stage 3)-Late
    • -Family recognition disappears
    • -Forgets how to eat
    • -Has problems with mobility
    • -Incontinence
    • -Return of infantile reflexes
  39. Nursing Diagnoses for Alzheimers
    • -Risk for injury
    • -Impaired verbal communication
    • -Chronic confusion
    • -Disturbed sleep pattern
    • -Imabalanced nutrition
    • -Caregiver role strain
  40. Anti-Alzheimer's Drugs
    • -Cognex
    • -Aricept
    • -Exelon
    • -Razadyne
    • -Namenda-Stage 3
  41. A nursing diagnosis appropriate for a client with Alzheimer's disease, regardles of the stage would be
    risk for injury
  42. Which problem is not considered a causative agent in delirium?
    Down Syndrome
  43. The daughter of a petient with early familial Alzheimer's Disease asks how AD can be detected. The nurse describes early warning signs of AD including what?
    Having no memory of preparing a meal and forgetting to serve or eat it
  44. A petient with Alzheimer's Disease had a nursing diagnosis of disturbed thought processes related to effects of dementia. An appropriate intervention for the patient is to what?
    Maintain familiar routines of sleep, meals, drug administration, and activities
  45. Which event would a client with early Alzheimer's Disease have greatest difficulty remembering?
    What the client ate for breakfast
  46. A 69-year old patient is admitted to the hospital with a urinary infection and a possible bacterial sepsis. The patient is disoriented and has a disturbed sleep-wake cycle. The nurse administers a mini-mental state examination to differentiate among various cognitive disorders, primarily because what?
    Delirium can be reversed by treating the underlying causes
  47. Health
    A dynamic and relative state that applies to individuals, families, and groups, and is described in degrees of wellness/illness resulting from met or unmet needs.
  48. Wellness
    • -Self-responsibility
    • -Daily decision making about health, involving whole being
  49. Basic Human Needs Model of Health
    Basic human needs are elements that are necessary for human survival and health. Example: Maslow's Hierarchy of Needs
  50. Health Continuum Model
    Death on one end and high-level wellness on the other
  51. Health Belief Model
    • -Addresses the relationship between a person's beliefs and behaviors.
    • -Explains why some people maintain health and treat illness while others fail to protect themselves
  52. Health Promotion Model
    • -Complimentary counterpart to models of health protection
    • -Increasing a clients level of well-being
  53. Hollistic Health Models
    • -Clients are seen as the ultimate experts regarding their own health
    • -Interventions are complimentary and alternative
  54. Primary Prevention
    • -True prevention
    • -Immunizations
    • -Physical activites
  55. Secondary Prevention
    • -Experiencing health problems and at risk for complications
    • -Screening techniques
    • -Treating early stages
  56. Tertiary Prevention
    • -Defect is permanent or irriversible
    • -Rehab activites
  57. Using Maslow's Model, which statement characterizes the highest level of need?
    I'm very proud of receiving that Employee of the Month reward at my hospital
  58. Which is an example of the emotional component of wellness?
    A client expresses frustration with his diabetic regimen
  59. A 55-year old teacher decides to have a colonoscopy. Which factor was likely a cue to action?
    The recent death of a friend from colon cancer
  60. A 24-yr-old diabetic client comes to the clinic with a 200 blood sugar. He says he wants to control his diabetes, but finds it hard to fit appropriate eating, fingersticks and insulin into his very active life. Best nursing diagnosis?
    Ineffective therapeutic regimen management
  61. Based on the fact that health is a personal perception, which person is likely to consider themselves healthy?
    Honors student who uses a wheelchair and volunteers for a suicide hotline
  62. Client: I was born to be fat. I can lose weight fine, but I don't have the willpower to keep it off.
    Using the health promotion model, what will the nurse focus on to help the client?
    Perceived self-efficacy
  63. Epidermis
    Avascular superficial layer
  64. Dermis
    Supportive connective tissue
  65. Subcutaneous tissue
    Attaches skin to underlying tissues and organs
  66. acute wound
    Occur suddenly, move rapidly and predictable through the repair process and result in durable closure
  67. chronic wound
    Frequently caused by vascular compromise, chronic inflammation, or repetitive insult to the tissue, and either failt to close in a timely manner or fail to result in durable closure
  68. Phases of Wound Healing
    • -Inflammatory Phase: begins at time of injury and lasts 3 to 4 days
    • -Proliferative or Reconstructive: 4 to 21 days
    • -Maturation or Remodeling Phase: 3 to 4 weeks
  69. Perineal Dermatitis
    A contact dermatitis in the perineal region, with the physical signs of one or any combination of erythema, swelling, oozing, vesiculation, crusting, and scaling.
  70. Preventing Perineal Dermatitis
    • -Identify patients at risk for incontinence
    • -Gentle cleansing
    • -Moisturize
    • -Protect skin from irritants
  71. Skin Tears
    A traumatic wound occuring principally on the extremeties of older adults, as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis or which separate both the epidermis and the dermis from underlying structures.
  72. Prevention Highlights for Skin Tears
    • -Identify patients at risk
    • -Avoid skin care products that dry the skin
    • -Avoid scrubbing and rubbing skin
    • -Use good transferring, positioning, turning and lifting techniques to reduce friction and shear
    • -Use protective padding
    • -Encourage patients to wear long sleeves and pants to protect skin
    • -Avoid adhesives or remove with care
  73. Pressure Ulcer
    A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
  74. Stage One Pressure Ulcer
    • -Intact skin with non-blanchable redness of a localized area.
    • -Painful, firm, soft, warmer, or cooler
  75. Stage Two Pressure Ulcer
    • -Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough
    • -intact or open/ruptured serum-filled blister
    • -Shiny or dry shallow ulcer without slough or bruising
  76. Stage Three Pressure Ulcer
    • -Full thickness tissue loss
    • -Subcutaneous fat may be visible
    • -Slough may be present but does not obscure the depth of tissue loss
    • -Undermining and tunneling may be included
  77. Stage Four Pressure Ulcer
    • -Full thickness tissue loss
    • -Exposed bone, tendon, or muscle
    • -Slough or escar may be present on some parts of wound bed
    • -Often include undermining and tunneling
  78. Unstageable Pressure Ulcer
    • -Full thickness tissue loss
    • -Base of ulcer covered by slough and/or eschar in the wound bed
  79. Suspected Deep Tissue Injury
    • -Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear
    • -Preceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler to adjacent tissue
  80. Prevention of DTI
    • -Cleanse skin after each incontinence episode and dry
    • -Reduce friction and shearing forces
    • -Do not massage skin
    • -Use skin barriers
    • -Avoid foam rings and donuts
    • -Reposition q 2 h
    • -Maintain adequate nutrition
  81. Wound Debridement
    any wound acute or chronic when necrotic tissue or foreign bodies are present or if the wound is infected
  82. Types of Wound Debridement
    • -Sharp: scalpel
    • -Mechnical: Whirlpool
    • -Enzymatic
    • -Autolytic: Own enzymes
  83. Surgical Wounds
    a healthy and uncomplicated break in the skin's continuity resulting from surgery
  84. Complications of Surgical Wounds
    • -Hemorrhage
    • -Infection
    • -Dehisence
    • -Evisceration
    • -Fistula
  85. Burns
    Acute wound caused by exposure to thermal extremes, causatic chemicals, electiricty or radiation
  86. Venous Ulcers
    Chronic skin and subcataneous lesions usualy found on the lower extremity at the pretibial and the medial supra malleolar areas of the ankle
  87. Preventing Venous Ulcers
    • -Treat varicosities
    • -Compression therapy to improve venous return
    • -Strengthening calf muscles
  88. Diabetic Neuropathic Foot Ulcers
    • -Due to the complication of diabetes, which may make the foot insensitate to forces of friction, shear and pressure.
    • -lead to dryness, cracking, callus formation and fissuring of the extremities with resulting ulcerations
    • -greater risk of infection, gangrene, and possible amputation
  89. Aterial Ulcers
    • caused by impairment in the arterial circulation that results in ischemia, necrosis and eventually ulcerations.
    • -moist wound dressing
  90. Mixed Venous-Arterial Ulcers
    -symptoms of both venous and arterial insufficiency
  91. Assessment of Impaired Skin Integrity
    • -Health History: medical and psychosocial
    • -Diagnostic Tests: cbc, albumin levels, sedimentation rate
  92. Wound Measurement
    -location, size, color, surrounding skin, drainage, pain, temperature
  93. Undermining
    • a closed passageway under the surface of the skin that is open only at the skin surface.
    • -often develops from shearing forces
  94. Braden Skin Scale
    • -Sensory Perception
    • -Moisture
    • -Activity
    • -Mobility
    • -Nutrition
    • -Friction and Shear
  95. Assessment of Wounds
    • -Serous
    • -Sanguiness
    • -Serosanguiness
    • -Purulent
    • -Red-Yellow-Black
  96. Factors Affecting Skin and Wound Healing
    • -Lifestyle: personal hygeine, nutrition and fluid status, activity and exercise, smoking, substance abuse
    • -Developmental: elderly
    • -Physiological: age, immunosupression, hypoxemia, diabetes, infection, neurological impairment, procedures, medication
    • -Environmental: moisture, friction, and shear
  97. Nursing Diagnosis-Wound
    • -Risk for impaired skin integrity
    • -Impaired skin integrity
    • -Impaired tissue integrity
  98. Heat
    Sedative effect
  99. Cold
    local anesthetic effect
  100. Applying Heat and Cold
    • -apply both in dry or moist forms
    • -apply for 20-30 minutes
    • -rebound phenomenon
  101. Contraindications to Heat
    • -1st 24 hours after injury
    • -active hemorrhage
    • -localized malignant tumor
    • -skin disorders that cause redness or blisters
  102. Contraindications to Cold
    • -open wounds
    • -impaired circulation
    • -allergy or hypersensitivity to cold
  103. When changing the dressing on a full thickness wound, the nurse charts, "wound bed covered with granulation tissue." On inspection, the nurse found that the wound bed tissue was?
    beefy, red, moist, and granular
  104. The nurse assess a surgical client the morning of the first postoperative day. Signs of a local inflammatory response that the nurse expects to find include?
    redness and heat of the incision
  105. A pressure ulcer is an example of what type of wound?
    Chronic wound, open, possibly contaminated
  106. Your client has yellow drainage from her wound. What does this indicate?
    It is unclear if this wound is infected
  107. A basic principle of wound management for all open wounds is to what?
    Protect new granulationand epithelial tissue
  108. When documenting normal findings of an assessment of the patient's skin, which of the following entries by the nurse is most appropriate?
    Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems with skin
  109. A patient's 6'3cm leg wound has a 2-mm black area surrounded by yellow-green semi liquid material. Which dressing will the nurse anticipate using for wound care?
    Hydrocolloid dressing (DuoDerm)
Card Set
Nursing Test 2 TCC
Nursing Test 2 TCC