Nutrition
Elimination
Tissue Integrity
Sensory Perception
Fundamental Concepts
100

Nutrients are substances found in food that are used by the body to promote normal growth, maintenance, and repair.

What is Nutrients?

100

How many times do you urinate during 24 hours? Has this pattern changed recently?
Do you need to get out of bed to void at night? How often?


What are some voiding pattern questions to ask clients?

100

Skin Hydration

What does turgor assess?

100

Visual acuity test

What does Rosenbaum test for? 

100

Physiological needs, Safety needs, Social belonging(Love and Belonging), Esteem, and Self-actualization

What are the five levels of Maslow's Hierarchy of Basic needs?

200

Flaccid muscles, mental status change, dry, scaly skin, weakness and fatigue, changes in weight, dull eyes, etc.

What are some malnutrition findings?

200

>30 mL/hour

What is the minimal urine output?

200

The Braden Scale rates a client's risk for alternations in tissue integrity using six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

What is the Braden Scale?

200

Normal Findings: When the patient's head is flexed, the hips and knees should not flex upward

What are some normal findings for Brudzinski sign?

200

P-Provocation (Precipitating cause)Q-Quality R-Region S-Severity T-Timing

What does the mnemonic PQRST stand for?

300

25 to 29.0 is overweight

What is the BMI for overweight?

300

Alcohol, caffeinated beverages and foods, dairy (milk, cheese, cream and ice cream), spicy foods, beverages that contain fructose

What are some foods and beverages to avoid if the client is experiencing diarrhea?

300

Older adults, immobility, obesity, anemia, impaired circulation, fever, dehydration, impaired cognitive functioning, neurologic disorder

What are some risk factors for skin breakdown?

300

A Romberg test is positive when you have a loss of balance when you close your eyes during the test

What is a positive finding for Romberg test?

300

Hypothermia, Tachycardia, Thready weak pulse, Hypotension, Confusion, mucous membranes, weakness

What are some expected findings for dehydration?

400

Macronutrients and micronutrients

What are the essential nutrients?

400

An increase in sodium leads to decreased urination.

Caffeine and alcohol intake lead to increased urination. 

How does diet affect urination? 

400

Severe, 8mm, prolonged skin response

What does a pitting edema of 4+ mean?

400

Minimize overall stimuli, provide a private room, reduce lights and noises, limit visitors, ensure pain is adequately managed

What are some interventions for clients experiencing sensory overload?

400

Baked potatoes, banana, spinach, plain, nonfat yogurt, prune juice

What are some foods high in potassium?

500

Slow the instillation rate, notify the provider, confer with the dietitian, and provide skin care and protection

What interventions should be taken for a client receiving enteral feedings who is experiencing diarrhea 3 or more times in 24 hours?

500

Collect for 24 hr or other duration.

Discard the first voiding.

Collect all other urine. Refrigerate, label, and transport the specimen.

What is the nursing action for a Timed urine (24-hour)?

500

Assess head and shoulder for strength

What does the cranial nerve XI assess?

500

Tinnitus(ringing, roaring, humming in ears), dizziness, hears poorly in a noisy environment, speaks loudly, no otoscopic finding

What are some sensorineural hearing loss findings?

500

pH less than 7.35 and PaCo2 greater than 45. 

- Shortness of breath, anxiety and confusion, fatigue, tremors, lethargy

What are some assessment findings with respiratory acidosis?

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