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Nur |! 155 |! exam |! 2 |! with |! accurate |!
detailed |! answers
what |! is |! holism |! - |! Correct |! answer |! ✔treating |! your |! patient |! as |! a |! whole |! (sleep |! habits, |! eating |! habits, |! wellbeing) what |! are |! the |! three |! levels |! of |! prevention |! - |! Correct |! answer |! ✔primary, |! secondary, |! tertiary what |! is |! primary |! prevention |! and |! what |! are |! some |! examples: |! - |! Correct |! answer |! ✔focuses |! on |! health |! promotion |! and |! protection |! against |! specific |! health |! problems. |! the |! purpose |! is |! to |! decrease |! the |! risk |! or |! exposure |! of |! the |! individual |! or |! community |! to |! disease (ex: |! health |! ed, |! immunizations, |! sanitation) what |! is |! secondary |! prevention |! and |! what |! are |! some |! examples: |! - |! Correct |! answer |! ✔focuses |! on |! the |! early |! identification |! of |! health |! problems |! and |! prompt |! intervention |! to |! alleviate |! health |! problems. |! Its |! goal |! is |! to |! identify |! individuals |! in |! an |! early |! stage |! of |! a |! disease |! process |! and |! to |! limit |! future |! disability (ex: |! screenings, |! regular |! checkups, |! self-examination)
what |! is |! tertiary |! prevention |! and |! what |! are |! some |! examples: |! - |! Correct |! answer |! ✔Begins |! after |! an |! illness, |! when |! a |! defect |! or |! disability |! is |! fixed, |! stabilized, |! or |! determined |! to |! be |! irreversible. |! Its |! focus |! is |! to |! help |! rehabilitate |! individuals |! and |! restore |! them |! to |! an |! optimum |! level |! of |! functioning |! within |! the |! constraints |! of |! the |! disability. |! (ex: |! support |! group, |! teaching |! someone |! with |! diabetes |! how |! to |! prevent |! complications, |! rehab) lifespan |! considerations |! for |! an |! infant: |! - |! Correct |! answer |! ✔Infant- parent |! attachment/bonding |! Breast-feeding |! Sleep |! patterns |! Playful |! activity |! to |! stimulate |! development |! Immunizations |! Safety |! promotion |! and |! injury |! control lifespan |! considerations |! for |! children: |! - |! Correct |! answer |! ✔Nutrition |! Dental |! checkups |! Rest |! and |! exercise |! Immunizations |! Safety |! promotion |! and |! injury |! control lifespan |! considerations |! for |! adolescents: |! - |! Correct |! answer |! ✔Communicating |! with |! the |! teen |! Hormonal |! changes |!
Weight |! control Maslow's |! Hierarchy |! of |! Needs |! - |! Correct |! answer |! ✔physiological, |! safety |! and |! security, |! love/belonging, |! self |! esteem, |! self-actualization what |! is |! healthcare |! adherence? |! - |! Correct |! answer |! ✔compliance |! with |! medical |! treatment what |! factors |! influence |! adherence |! - |! Correct |! answer |! ✔-motivation -degree |! of |! lifestyle |! change -severity |! of |! healthcare |! problem -value |! on |! reducing |! the |! threat |! of |! illness -ability |! to |! understand |! and |! perform |! behaviors -beliefs -complexity |! and |! duration |! of |! therapy -type |! of |! relationship |! with |! healthcare |! providers -cost |! of |! therapy decreasing |! the |! angle |! of |! the |! joint |! (bending |! elbow) |! - |! Correct |! answer |! ✔flexion increasing |! the |! angle |! of |! the |! joint |! (straightening |! arm) |! - |! Correct |! answer |! ✔extension
Further |! extension |! or |! straightening |! of |! a |! joint |! (bending |! head |! backwards) |! - |! Correct |! answer |! ✔hyperextension movement |! of |! the |! bone |! away |! from |! the |! midline |! of |! the |! body |! - |! Correct |! answer |! ✔abduction movement |! of |! the |! bone |! towards |! the |! midline |! of |! the |! body |! - |! Correct |! answer |! ✔adduction movement |! of |! the |! bone |! around |! it |! central |! axis |! - |! Correct |! answer |! ✔rotation movement |! of |! the |! distal |! part |! of |! the |! bone |! in |! a |! circle |! while |! the |! proximal |! end |! remains |! fixed |! - |! Correct |! answer |! ✔circumduction turning |! the |! sole |! of |! the |! foot |! outward |! by |! moving |! the |! ankle |! joint |! - |! Correct |! answer |! ✔eversion turning |! the |! sole |! of |! the |! foot |! inward |! by |! moving |! the |! ankle |! joint |! - |! Correct |! answer |! ✔inversion
what |! is |! the |! BMI |! for |! someone |! that |! is |! obese |! - |! Correct |! answer |! ✔30.0-
what |! is |! the |! BMI |! for |! someone |! that |! is |! extremely |! obese |! - |! Correct |! answer |! ✔40.0 |! and |! over what |! is |! included |! in |! the |! food |! guide |! pyramid? |! - |! Correct |! answer |! ✔grains, |! vegetables, |! fruits, |! oils, |! milk, |! meat |! and |! beans what |! is |! included |! in |! the |! myplate? |! - |! Correct |! answer |! ✔fruits, |! vegetables, |! protein, |! grains, |! dairy with |! the |! food |! guide |! pyramid |! and |! my |! plate, |! is |! it |! guaranteed |! you |! will |! get |! all |! essential |! nutrients? |! - |! Correct |! answer |! ✔no, |! just |! will |! come |! close what |! is |! normal |! albumin |! levels? |! - |! Correct |! answer |! ✔3.5- what |! does |! it |! indicate |! if |! albumin |! levels |! are |! below |! 3.5? |! - |! Correct |! answer |! ✔malnutrition, |! protein |! depletion |! in |! diet Risk |! factors |! for |! nutritional |! problems: |! Diet |! history |! - |! Correct |! answer |! ✔-chewing |! or |! swallowing |! difficulty
-inadequate |! food |! budget -inadequate |! food |! intake inadequate |! food |! prep -inadequate |! food |! storage -IV |! fluids -living/eating |! alone -physical |! disabilities -restricted |! or |! fad |! diet Risk |! factors |! for |! nutritional |! problems: |! Medical |! history |! - |! Correct |! answer |! ✔-adolescent |! pregnancy |! or |! pregnancies |! close |! together -alcohol -chronic |! disease -fluid/electrolyte |! imbalance -GI |! problems -cognitive |! impairment -surgery -wt |! loss |! or |! gain Risk |! factors |! for |! nutritional |! problems: |! Medication |! history |! - |! Correct |! answer |! ✔-antacids -antidepressants
Bouillon fat-free |! broth Clear |! fruit |! juices |! (apple, |! cranberry, |! grape) |! Other |! fruit |! juices strained Popsicles |! Gelatin |! Sugar honey Hard |! candy what |! food |! is |! in |! a |! full |! liquid |! diet? |! - |! Correct |! answer |! ✔All |! foods |! on |! clear |! liquid |! diet |! plus: |! Milk |! and |! milk |! drinks Puddings custards Ice |! cream sherbet Vegetable |! juices Refined |! or |! strained |! cereals |! (e.g., |! cream |! of |! rice) |! Cream butter margarine Eggs |! (in |! custard |! and |! pudding) |! Smooth |! peanut |! butter
Yogurt what |! food |! is |! in |! a |! soft |! food |! diet? |! - |! Correct |! answer |! ✔All |! foods |! on |! clear |! and |! full |! liquid |! diets, |! plus: |! Meat: |! all |! lean, |! tender |! meat, |! fish, |! or |! poultry |! (chopped, |! shredded); |! spaghetti |! sauce |! with |! ground |! meat |! over |! pasta |! Meat |! alternatives: |! scrambled |! eggs, |! omelet, |! poached |! eggs; |! cottage |! cheese |! and |! other |! mild |! cheese |! Vegetables: |! mashed |! potatoes, |! sweet |! potatoes, |! or |! squash; |! vegetables |! in |! cream |! or |! cheese |! sauce; |! other |! cooked |! vegetables |! as |! tolerated |! (e.g., |! spinach, |! cauliflower, |! asparagus |! tips), |! chopped |! and |! mashed |! as |! needed; |! avocado |! Fruits: |! cooked |! or |! canned |! fruits; |! bananas, |! grapefruit |! and |! orange |! sections |! without |! membranes, |! applesauce |! Breads |! and |! cereals: |! enriched |! rice, |! barley, |! pasta; |! all |! breads; |! cooked |! cereals |! (e.g., |! oatmeal) |! Desserts: |! soft |! cake, |! bread |! pudding how |! to |! prevent |! food |! born |! illnesses? |! - |! Correct |! answer |! ✔▪ |! Reinforce |! hygienic |! handling |! of |! food |! and |! dishes: |! ▪ |! Wash |! hands |! before |! preparing |! food. |! ▪ |! Wash |! hands |! and |! all |! dishes, |! utensils, |! and |! cutting |! boards |! with |! hot |! water |! and |! soap |! after |! contact |! with |! raw |! meats. |! ▪ |! Defrost |! frozen |! foods |! in |! the |! refrigerator. |! ▪ |! Cook |! beef, |! poultry, |! and |! eggs |! thoroughly. |! Use |! a |! cooking |! thermometer. |! ▪ |! Refrigerate |! leftovers |! promptly |! (at |! 40°F |! [5°C] |! or |! less) |! and |! keep |! no |! more |! than |! 3 |! to |! 5 |! days. |! ▪ |! Wash |! or |! peel |! raw |! fruits |! and |! vegetables. |!
- |! Fever |!
- |! Nasogastric |! suction |!
- |! Abnormal |! drainage |! or |! wound |! losses |! Insufficient |! intake |! due |! to: |!
- |! Anorexia |! • |! Nausea |! • |! Inability |! to |! access |! fluids |! • |! Impaired |! swallowing |!
- |! Confusion, |! depression Isotonic |! Fluid |! Volume |! Deficit |! Clinical |! Manifestations: |! - |! Correct |! answer |! ✔Complaints |! of |! weakness |! and |! thirst |! Weight |! loss: |!
- |! 2% |! loss |! = |! mild |! FVD |!
- |! 5% |! loss |! = |! moderate |!
- |! 8% |! loss |! = |! severe |! Fluid |! intake |! less |! than |! output |! Decreased |! tissue |! turgor |! Dry |! mucous |! membranes, |! sunken |! eyeballs, |! decreased |! tearing |! Subnormal |! temperature |! Weak |! pulse; |! tachycardia |! Decreased |! blood |! pressure |! Postural |! (orthostatic) |! hypotension |! (significant |! drop |! in |! BP |! when |! moving |! from |! lying |! to |! sitting |! or |! standing |! position) |! Decreased |! capillary |! refill |! Decreased |! central |! venous |! pressure |! Decreased |! urine |! volume |! (<30 |! mL/hr) |! Increased |! specific |! gravity |! of |! urine |! (>1.030) |! Increased |! hematocrit |! Increased |! blood |! urea |! nitrogen |! (BUN)
Isotonic |! Fluid |! Volume |! Deficit |! Nursing |! Interventions |! - |! Correct |! answer |! ✔Assess |! for |! clinical |! manifestations |! of |! FVD. |! Monitor |! weight |! and |! vital |! signs, |! including |! temperature. |! Assess |! tissue |! turgor. |! Monitor |! fluid |! intake |! and |! output. |! Monitor |! laboratory |! findings. |! Administer |! oral |! and |! IV |! fluids |! as |! indicated. |! Provide |! frequent |! mouth |! care. |! Implement |! measures |! to |! prevent |! skin |! breakdown. |! Provide |! for |! safety |! (e.g., |! provide |! assistance |! for |! a |! client |! rising |! from |! bed |! or |! chair). Isotonic |! Fluid |! Volume |! Excess |! Risk |! Factors: |! - |! Correct |! answer |! ✔Excess |! intake |! of |! sodium-containing |! IV |! fluids |! Excess |! ingestion |! of |! sodium |! in |! diet |! or |! medications |! (e.g., |! sodium |! bicarbonate |! antacids |! such |! as |! Alka-Seltzer |! or |! hypertonic |! enema |! solutions |! such |! as |! Fleet's) |! Impaired |! fluid |! balance |! regulation |! related |! to: |!
- |! Heart |! failure |!
- |! Renal |! failure |!
- |! Cirrhosis |! of |! the |! liver Isotonic |! Fluid |! Volume |! Excess |! Clinical |! Manifestations: |! - |! Correct |! answer |! ✔Weight |! gain: |!
- |! 2% |! gain |! = |! mild |! FVE |!
Signs |! and |! Symptoms |! of |! fluid |! volume |! deficit? |! - |! Correct |! answer |! ✔dry, |! sticky |! mucous |! membranes, |! weak |! tachycardia |! pulse, |! low |! BP, |! decreased |! skin |! turgor Signs |! and |! Symptoms |! of |! fluid |! volume |! excess? |! - |! Correct |! answer |! ✔short |! of |! breath, |! confused, |! bounding |! pulse, |! distended |! veins, |! high |! BP how |! to |! position |! someone |! with |! FVE: |! - |! Correct |! answer |! ✔fowlers what |! is |! considered |! an |! intake? |! - |! Correct |! answer |! ✔fluids, |! IV |! meds, |! IV |! fluid, |! foods |! liquid |! at |! room |! temp what |! is |! considered |! output? |! - |! Correct |! answer |! ✔urine, |! vomit, |! diarrhea, |! wound |! drainage Signs |! and |! symptoms |! of |! hyponatremia |! (low |! sodium) |! - |! Correct |! answer |! ✔Lethargy, |! confusion, |! apprehension |! Muscle |! twitching |! Abdominal |! cramps |! Anorexia, |! nausea, |! vomiting |! Headache |! Seizures, |! coma |!
Laboratory |! findings: |! Serum |! sodium |! < |! 135 |! mEq/L |! Serum |! osmolality |! < |! 280 |! mOsm/kg signs |! and |! symptoms |! of |! hypernatremia |! (high |! sodium): |! - |! Correct |! answer |! ✔Thirst |! Dry, |! sticky |! mucous |! membranes |! Tongue |! red, |! dry, |! swollen |! Weakness |! Severe |! hypernatremia: |!
- |! Fatigue, |! restlessness |!
- |! Decreasing |! level |! of |! consciousness |!
- |! Disorientation |!
- |! Convulsions |! Laboratory |! findings: |! Serum |! sodium |! > |! 145 |! mEq/L |! Serum |! osmolality |!
|! 300 |! mOsm/kg signs |! and |! symptoms |! of |! hypokalemia |! (low |! potassium): |! - |! Correct |! answer |! ✔Muscle |! weakness, |! leg |! cramps |! Fatigue, |! lethargy |! Anorexia, |! nausea, |! vomiting |! Decreased |! bowel |! sounds, |! decreased |! bowel |! motility |! Cardiac |! dysrhythmias |!
Muscle |! tremors, |! cramps; |! if |! severe |! can |! progress |! to |! tetany |! and |! convulsions |! Cardiac |! dysrhythmias; |! decreased |! cardiac |! output |! Positive |! Trousseau's |! and |! Chvostek's |! signs |! (see |! Table |! 52-8 |! and |! Figure |! 52-12) |! Confusion, |! anxiety, |! possible |! psychoses |! Hyperactive |! deep-tendon |! reflexes |! Laboratory |! findings: |! Serum |! calcium |! < |! 8.5 |! mg/dL |! (total) |! or |! 4.5 |! mEq/L |! (ionized) |! Lengthened |! QT |! intervals |! Prolonged |! ST |! segments signs |! and |! symptoms |! of |! hypercalcemia |! (high |! calcium): |! - |! Correct |! answer |! ✔Lethargy, |! weakness |! Depressed |! deep-tendon |! reflexes |! Bone |! pain |! Anorexia, |! nausea, |! vomiting |! Constipation |! Polyuria, |! hypercalciuria |! Flank |! pain |! secondary |! to |! urinary |! calculi |! Dysrhythmias, |! possible |! heart |! block |! Laboratory |! findings: |! Serum |! calcium |! > |! 10.5 |! mg/dL |! (total) |! or |! 5.5 |! mEq/L |! (ionized) |! Shortened |! QT |! intervals |! Shortened |! ST |! segments
what |! three |! things |! can |! you |! assess |! when |! it |! comes |! to |! fluid |! and |! electrolyte |! without |! a |! physician |! order: |! - |! Correct |! answer |! ✔weight |! (will |! show |! if |! really |! off) vitals I&O if |! a |! patient |! has |! an |! IV, |! what |! do |! we |! look |! for |! at |! the |! injection |! site: |! - |! Correct |! answer |! ✔redness, |! swelling, |! pain |! (if |! any |! discontinue |! and |! redo |! it |! in |! a |! different |! place) what |! is |! polyuria? |! - |! Correct |! answer |! ✔excessive |! urination What |! is |! oliguria? |! - |! Correct |! answer |! ✔Decreased |! urine |! output What |! is |! anuria? |! - |! Correct |! answer |! ✔absence |! of |! urine What |! is |! enuresis? |! - |! Correct |! answer |! ✔involuntary |! urination what |! much |! is |! normal |! urine |! output |! for |! each |! hour? |! - |! Correct |! answer |! ✔ 30 |! ml can |! you |! measure |! urine |! output |! in |! a |! catheter |! bag? |! - |! Correct |! answer |! ✔no, |! must |! drain |! it |! to |! measure
