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Exam 4 Review Flashcards | StudBud
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Exam 4 Review
Exam 4 Review
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1
Priority for crisis intervention is? (SATA)
Type of insurance coverage
Evaluate resources and support services
an in-depth analysis of the patient's situation
Employment status
2
Signs of fluid volume overload include?
edema
flattened neck veins
dry skin
hypotension
3
complementary alternative medicine (SATA)
massage therapy
aromatherapy
acupuncture
cognitive behavioral therapy
4
Elevated sodium levels indicate dehydration. Normal levels are:
116-124 mEq/L
108-116 mEq/L
132-145 mEq/L
124-132 mEq/L
5
What helps reduce stress in the body?
crying
meditation and exercise
binge-watching
complaining
6
Prevention of Urinary Tract Infection include all of the following EXCEPT:
Wearing tight-fitting clothing
Drinking 6-8 glasses water/day
Urinating before and after intercourse
Wiping from front to back
7
Which sodium disorder can be caused by dehydration
Similar answer.
Funny answer.
Hyponatremia
Hypernatremia
8
Position used to perform a urinary catherization
Sim
Dorsal Recumbent
Supine
Prone
9
BOWEL TRAINING INVOLVES?
CREATING A COLOSTOMY
TODDLERS
SITTING ON COMMODE FOR 15 -30 MINUTES AFTER MEALS
INSERTION OF A RECTAL TUBE
10
Sodium elevates during dehydration for what reason?
In response to a lowered potassium
It doesn't really
In response to the decrease in body fluid to hang on to more
From eating too much salt
11
What is the nursing assessment prior to giving an enema?
Auscultate Bowel sounds for normal, hypo, hyper sounds
Palpate the abdomen for tenderness
Inspect the abdomen for distention and symmetry
All of the above
12
Stress can elevate vital signs.
False
True
13
Urinary Retention
The loss of voluntary voiding control
Distention of bladder due to holding urine
The inability to void even with an urge to void
Loss of bladder control
14
What should the family members avoid during the hospitalization of their loved one?
Noise
Silence
Cry
Talk
15
During which phase of stress do vital signs collapse?
Alarm phase
Exhaustion phase
Resistance phase
16
a urinary catheter is a
Closed urinary drainage system
a urinary drainage system placed for control of the bladder
open urinary drainage system
a urinary drainage system placed to strengthen the bladder
17
24 hour urine?
throw last out keep for 24 hours and clean catch each time
throw first out keep all the rest for 24 hours on ice
18
Stress Incontience
periodic involuntary urination
leakage of a small amount of urine when bladder is too full
urgency
caused by cough, sneeze, or strain
19
"Tell me more about that" uses which form of therapeutic communication.
Making observations
Exploring
Offering self
Giving information
20
Signs & symptoms of hypernatremia?
Muscle cramps, twitching, seizures.
Flaccid paralysis & dysrhythmias.
Thirst, dry mouth, seizures.
Positive Trousseau sign.
21
Physiological manifestations of stress include?
Sweating, increased blood glucose levels & dilated pupils
Flush skin, decreased muscle control and vomiting
Increased blood pressure, reduced blood glucose & chest pain
Slow heart rate, low blood pressure & severe headaches
22
Stressor is the stimuli to change, alter behavior, or adapt to a situation
False
True
23
The nursing assistant will administer an enema and positions the resident:
L side SIMS
all fours
24
Fluid volume excess?
Hypovolemia
Third-Spacing
Hypervolemia
25
Absolute hypovolemia is due to
Fluid moving into the interstitial space
Fluid loss from haemorrhage, GI loss or drains
Severe diaphoresis and dehydration
Fluid loss due to burns
26
Symptoms of hypokalemia?
shortness of breath, agitation, restlessness
confusion, convulsion
Nausea, vomitting diarhea
muscle weakness, dizziness, heart palpitations
27
S/S of Exhaustion
Vasodilation, Increased BP, Increased pulse + RR
Vasoconstriction, decreased BP, Increased pulse +RR
Vasodilation, decreased BP, Increased pulse + RR
Vasoconstriction, Increased BP, Decreased pulse + RR
28
Fluid volume excess
Increased BP; increased HR
Decreased BP; decreased HR
Increased BP; decreased HR
Decreased BP; increased HR
29
Chronic stress...
Both a) and d)
Causes AIDS
Contributes to persistent inflammation
Brings a risk of clogged arterys
30
if a patient does not have atleast 30ml of output per hour it is a medical emergency & you should notify the provider
True
False
31
How can healthcare organizations support nurses to reduce burnout?
Isolation and indifference
Resources and Counselling
Limited support
Overworked schedules
32
urostomy
surgically created to drain urine, output is urine or possibly mucus
surgically created opening in small intestine, output includes liquid
surgically created opening in colon, output includes liquid or formed stool
33
Using therapeutic communication skills; how should the nurse assist with problem-solving and crisis management
Psychobiological interventions
Promotion of self-care activities
Tell the client not to stress
Explore patient concerns
34
Hypertonic fluid examples
D10 & D50
0.45% NaCl & 0.33% NaCl
3% NaCl
D5LR & D5 1/2 NS
35
Hypertonic fluid...
cause fluid to shift from the intracellular to the intravascular space
cause fluids to shift from the intravascular out to the intracellular space
fluid moves equally between compartments
36
Define Alarm stage
The body's functions are reduced to respond to stress (fight or flight)
Promotes adaption
Everything in excess
The body's functions are heightened to respond to stress (fight or flight)
37
Pt with ostomy - assessment findings of normal, health stoma?
Purple-blue and dry
Pale and dry
Red and moist
Black and crusty
38
Signs of adaptive coping
increased impatience
worse moods
substance use
journaling, yoga, healthy diet
39
What is the main reason the nurse keeps indwelling urinary catheter tubing free of kinks?
Kinks in the tubing cause the patient unnecessary discomfort
Kinks result in scant, dark amber-colored urine.
Kinks are associated with the development of UTI
Kinks allow the drainage bag to become overly full.
40
Bad stress
Distress
Eustress
41
Symptoms of hyponatremia include:
headache,chest pain, fever and muscle twitching
headache, change in mental status and muscle twitching
chestpain, fever, and pericardial rub
headache, rapid breathing and high energy level
42
S & S of Fluid Volume Deficit/Hypovolemia/Dehydration
tachypnea, cold & clammy skin, and acute weight gain
hypotension, flattened neck veins, & dry mucous membranes
weakness, diminished capillary refill, & ascites
tachycardia, hypotension, & distended neck veins
43
Isotonic fluid
has the same tonicity as blood and does not cause a fluid shift
cause the body cells to swell
adds water to the bloodstream
causes the cells to shrink by adding solutes to the bloodstream
44
Empty the ostomy pouch:
every 4 to 6 hours
when it is 1/3 to 1/2 full
once a shift
every am and pm
45
method of minimizing stress for a hospitalized patient (SATA)
Keep the TV on the channel that explains hospital policy
Allow the patient to make as many choices as possible
Remove all personal jewerely
Allow personal belonging in the room
Only allow family to visit
Keep all visitors out of the room
46
Overflow Incontinence
caused by trauma or damage to the nervous system
sudden intense urge to urinate followed by an involuntary loss of urine
continuous leaking of urine day and night or periodic leaking
Inability to empt the bladder or retention, dribbling urine
47
Proper care of a indwelling urinary catheter includes?
emptying the bag only when it is completely full
placing the bag on the patient's lap when transporting them
cleaning the tube from the patient to the bag
measuring urine output once a shift
48
To alter the stressor (The thing that stresses us), we can choose to
Manage our time better
Let others dictate how we should react
Hold our ground and stick with it
Keep confidential and avoid the topic
49
What activates sympathetic nervous system?
chocolate consumption
deep breathing
stressful situations
long walks
50
Which is a contraindication of administering an enema? SATA
Rectal Bleeding
Fecal Impaction
Constipation
Incontinence
Increased intracranial pressure
Abdominal distention
51
Hyponatremia can cause cerebral edema.
True
False
52
Situational stress is
Can threaten health
Random, unpredictable
Associated with life stages
Unable to meet demands
53
The patient with an indwelling urinary catheter is ordered to ambulate twice daily. The nurse should instruct the UAP to
Cover the bag with a pillow or sleeve
Teach patient on the care of the urinary bag
raise the bag above the bladder level
keep the bag below the bladder level
54
In catheter care, the proper cleaning of the urinary meatus consists of
it doesn't matter
cleansing towards the meatus
clamping the catheter to make sure there are no leaks
cleansing away from the meatus
55
What is the education given after inserting a Foley Catheter (SATA)
Pull out the catheter if there is pain
Ensure that the pt urine bag is under the pts bladder
Keep urine bag on the IV fluid pole
Educate pt on UTI and peri care
56
Hypertonic fluid ____________ blood volume.
Decreases
Has no affect on
Increases
