Foundations Exam 4 Fall 2023 Study Guide PDF

Foundations Exam 4 Fall 2023 Study Guide This study guide is made available to assist in your preparation for the exam and is NOT all inclusive. 75 item exam; multiple choice; select all that apply, matching, math problems, drag and drop, and hot spot. As you prepare for the exam, use your class no...

Foundations Exam 4 Fall 2023 Study Guide This study guide is made available to assist in your preparation for the exam and is NOT all inclusive. 75 item exam; multiple choice; select all that apply, matching, math problems, drag and drop, and hot spot. As you prepare for the exam, use your class notes, ppt’s, ATI Engage Fundamentals, and reading assignments. You will have 75 minutes to complete the exam on TCUOnline or ATI. Do the practice questions! This is not just rote memorization. You will have to apply what you have learned to situations and choose the best answer. TOPIC/CONCEPT CONTENT Bowel Elimination Unexpected findings of abdominal assessment/stool tests and conditions the (12-20 questions) unexpected findings might indicate Impacted vs constipation--- laxatives aren’t working its impaction, we can try enema, if that doesn’t work its impaction, also you will see leaky stool. Doctor could order CT to see whats up Factors affecting bowel elimination Age Fluid intake Pain Diet Meds/laxatives/cathartics Common elimination problems and terms; Constipation, Diarrhea, impaction, hemorrhoid, etc Constipation- what can cause: decreased mobility, opioids, sedatives, what can we do? Increase fluid intake, as stool moves through large intestine, this is where we absorb water, descending colon is where we get dry, large clumps of stool. Impaction- interventions: laxatives, enema (softens stool, lubricates rectum), digital disimpaction Diarrhea – increases peristalsis, Dehydration, Hypovolemia, electrolyte imbalance (POTASSIUM) - Extended use of rectal tubes can cause stool incontinence Hemorrhoid- inflamed blood vessel in the rectum, lots of bleeding so ASSESS for bright red bleeding treated: steroid meds, creams, numbing meds for pain/discomfort, waffle pillows to relieve pressure, look for BRIGHT RED If you see Black stool, Ask if taking Iron supplement Ostomy in small intestine- stool consistency is gonna be liquid, focus on hydration here for pt education, clean stoma, empty bag when half way full RISK FOR SKIN BREAKDOWN and infection Ostomy in large intestine- dry, hard, only expelling a few times/day pt education is avoiding foods that give them gas. Offer support groups Changes related to aging, immobility, opioids Nursing diagnoses and interventions related to bowel elimination Enema – to try to loosten up stool Spring 2023 DB  isotonic ENEMA safest bc no water shifted, it moistens and expands colon hypertonic ENEMA– fluid overload, helps drain it out NEVER DO IN RENAL PATIENTS oil retention – soften stool and lubricate stool antacids can make stool whiteish Urinary Unexpected findings related to elimination: UTI exemplar Elimination - Delirium, confusion (12-20 questions) - Symptoms: dysuria, frequency (spasms) dark, cloudy urine with foul odor - Common uti patients- bph, immobility, pregnancy - Uti bacteria: E.coli - Pee after sex, wipe front to back - Avoid Tight clothing, showers no baths How do I know based off of symtpions if localized or systemic uti Local- blood in urine, odor, frequency, cloudy urine Systemic= flank pain, fever, confusion, nausea/vomiting, delirium Assessment of urine characteristics - Cloudy, dark yellow – UTI - Normal urine is sterile - Contains fluids, salts, and waste products - Odor: not strong - Clarity- clear - BUN: 7-20 mg/dL - Creatinine: 0.6-1.2 mg/dL Urinalysis (UA); Culture and Sensitivity UA versus culture---, UA screens for UTI, kidney disease, other conditions, gives you the ph., urine specific gravity to determine dehydration, show glucose (should be little to none), and protein in urine, which could show kidney damage Content and clarity culture and sensitivity: takes longer, and used to screen for bacteria and organisms. Types of incontinence stress (pregnancy, sneezing, ascites) urge overflow, cant get full amount of urine out and some trickles out functional (cannot literally walk to the bathroom needed nurse didn’t show), etc) and urinary retention; Identify when given patient symptoms and signs Normal urinary output, minimal output/hour and significance of decreased urine output Normal output: 60ml/hr Output of less than 30 ml/hr may indicate decreased renal perfusion and should be reported to PCP asap Terms associated with urinary problems (anuria, dysuria, nocturia, oliguria, polyuria, hematuria, retention, etc). Oliguria is less than 400 ml/day and presents as changes in bp, flank pain Common disease conditions that affect urination (such as renal conditions, diabetes, bph, etc) Spring 2023 DB  The patient with kidney damage has increased urinary creatinine and increased serum levels. Nursing Diagnoses and interventions related to Urinary Elimination; catheterization; infection prevention Sensory/Cognitive Common terms and types of cognitive and sensory alterations Alterations For visual impairment – use clock method for food placement on plate and (12-20 questions) things around the room, maintain adequate lighting and photos, audiotapes if necessary, clear pathways For speaking impairment – focus on risk for dysphagia/aspiration Hearing impairment – create a quiet environment, most common sensory problem in elderly, maintain eye contact, make sure hearing aids are charged Sensory impairment- Decreased sensation in skin- keep doing skin assessments, make sure baths/showers aren’t too cold/too hot so feel temp for yourself, ice packs limit to 30 mins Sense of taste/gustatory – oral care, flavorful foods using salt-free alternatives, spice Cognitive impairment Factors affecting alterations Affecting Sensory: age, # of stimuli, meaningful stimuli, environmental factors: occupation. Recreation, social interaction, cultural factors COGNITION AND SENSATION Myopia- nearsightedness presbyopia- farsightedness Cataract- clouding of lens of the eye, causes blurry vision Glaucoma- causes increases intraocular pressure, puts pressure on optic nerve which leads to peripheral visual fields and possibly blindness Diabetic neuropathy : complication of diabetes mellitus where blood vessels of retina become damaged. Macular degeneration – cause is due to age, loss of vision in the central visual fields. leading cause of visual defects in the US. SENSORY DEFICITS Peripheral neuropathy: nerve damage away from the center of the body, caused by damage to sensory nerve fibers in the arms and legs anosmia: complete loss of smell presbycusis: age-related hearing loss, usually sensorineural in nature Meniere’s disease: progressive hearing loss that causes vertigo, and tinnitus Differentiate Delirium, Dementia, Depression COGNITIVE IMPAIRMENT – ask fam ab baseline Delirium - Problem elsewhere in body, check for UTI, or sodium imbalance, Treat physical problem and it should resolve Spring 2023 DB  - THINK method (toxicity, hypoxemia, infection/immobility, nonpharmacological, k+/electrolyte imbalance - Dementia - Brain problem - Irreversible - Focus on family support Depression - Focus on physical cues, immobility comes with depression, - Depression assessment: has there been Recent life changes, issues w personal life - Define & differentiate sensory deficits, deprivation, overload &factors Sensory overload- interventions: promote sleep, reduce environmental stimuli, clustering care, speak calmly and slowly (can be from pain, dyspnea, anxiety) Sensory deprivation- interventions: provide care to facilitate senses, provide glasses, hearing aids, adaptive equipment to reduce sensory deficit, and determine ability to compensate if this is new. Types of aphasia Wernickes – receptive aphasia: patient cant make sense of what the other person is saying (inability to understand written or spoken language) Brocas – expressive aphasia: inability to name common things or simple ideas in words or writing (understanding and reading is still intact) ** intervetnions: provide picture board or whit4baord What is a mini-cog? - Used first when assessing patient to assess if cognitive impairment - for dementia or cognitive impairment Differentiate acute vs chronic confusion Nursing diagnoses &nursing interventions for sensory and cognitive alterations Cumulative Key concepts from previous exams (Up to 30 PAD questions) - pale skin, shiny skin, hairless, tingling feeling - intervention: anti-platelet, DANGLE LEGS, exercise for 30 mins PVD - brownish skin - edema - interventions: SCDs, ELEVATE legs, anticoagulant DVT - bedrest, elevate legs, no SCDS when clots appear, but you can only on 1 - can become PE if clot moves to lungs which can cause dyspnea Immobility - Increased risk for contractures - Pressure ulcer - Pneumonia Electrolyte (K and Na ) imbalances - Na not well regulated so you experience confusion, delirium - Na regulated BP so too high/too low can cause BP Spring 2023 DB  - Hyperkalemia worry about heart, look at BUN, creatinine (UP) GFR (goes down) - Hypocalcemia- tingling and numbness in fingers tactile disturbances, positive trousseaus Blood flow through the heart chart Right atrium, right ventricle, pulmonary artery, lungs, pulmonary veins, left atrium, left ventricle then out through aorta to rest of body Contact precautions – gown, standard mask, hand hygiene before and after, gloves How to use a cane- hold the cane on the stronger side, advance cane, advance weak leg, advance stronger leg COPD- rhonchi, dry cough, thick mucous, increased sputum, interventions: assess O2: should be between 88-92. Don’t put a mask on COPD pts, nasal cannula can be put on 5L but we don’t want to put too high bc we are trtying to ween patient off o2 CHF- presents as edema everywhere bc of overflow in the body, thin pink frothy sputum for CHF IV solution: Memorize isotonic: LR D5W Normal saline 0.9 Hypertonic D10W Michelin mama fluid volume excess - Diuretics - Fluid restriction - Daily weight - Diuretics then Hypertonic solution 3% which should help: - We want to oull water out of the cells and into the vein (intravascular) then to the kidneys Tired timmy (diarrhea, vomiting, sweating) fluid volume deficit - Monitor electrolytes - Give isotonic (LR, NS 0.9%) - Treat underlying cause Dusty harry - Give water to dilute electrolytes - If quick, Give iv fluid 0.45% NACL Bamboozled Spring 2023 DB  1. On assessment lower extremity demonstrates 2+ pitting edema the nurse documents this wound as o Venus stasis ulcer (vain problem Is edema, brownish discoloration around affected area) 2. Nurse is creating a plan of care for a pt w glaucoma, which nursing diagnosis best addresses the greatest concern of complication from this sensory deficit a. Risk for fall 3. The nurse documents this drainage as… (clear yellow, exudate) a. Serous (serous isn’t serious) 4. A nurse is teaching an alert client how to use a PCA pump system at home. How will the nurse explain what they must do to self manage pain? a. When you push the button, you will get the medicine 5. BMI of 26, what category a. Overweight 6. Patient whos mother has only a week to live, defting and rebelling at school, what stage is he in? a. Anger 7. NPO and fluid deficit for long period of time, what would indicate protein calorie malnutrition? a. Poor wound healing, apathy, edema 8. A period of time or state of mind where feelings of loss grief of mourning are experienced by the survivor after the death of a loved one is known as a. Bereavement (outward expression of grief (to express mourning is actions) 9. What is an occult blood test a. Tests for blood in the stool 10. Patient is experiencing urinary retention when patient has… a. Small amounts of urine voided 2 to 3 times per hour 11. Leslie has right abdominal pain for past two weeks from a surgical wound. How would nurse classify the pain a. Somatic, acute 12. Wha does SOLER mean? a. Sit squarly, open posture, lean towards the other, eye contact, relax 13. Is it ok to have a bit of sugar in your urine? a. NO, above 400 sugar level will probably spill over into urine and hyperglycemia 14. True or false? A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink. a. true Spring 2023 DB