Urinary
What is the most significant change in kidney function that occurs with aging?
Decreased glomerular filtration rate
What is the function of the stratum corneum?
Protects the body against the entry of pathogens
The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.
The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating?
1) Chemoreceptors
2) Photoreceptors
3) Proprioceptors
4) Mechanoreceptors
Photoreceptors
Unstageable Wound
Which urine specific gravity would be expected in a patient admitted with dehydration?
1) 1.002
2) 1.010
3) 1.025
4) 1.030
4) 1.030
Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration.
The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication?
Skin breakdown
A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
Partial-thickness wound
Partial-thickness wounds extend through the epidermis into the dermis.
Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?
1) Self-Care Deficit: Dressing and Grooming
2) Impaired Adjustment
3) Risk for Injury
4) Activity Intolerance
3) Risk for Injury
The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.
Venous Ulcer
Patient teaching for strengthening pelvic floor muscles
a. Kegel exercises
b. Strengthen by squeezing and relaxing as if stopping urination midstream.
c. Hold each contraction for 5 to 10 seconds and then rest for 5 to 10 seconds
A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?
1) Chronic urinary incontinence
2) Stigma associated with mental illness
3) Risk for recurring infections
4) Auditory hallucinations (hearing things)
2
Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenario suggests that the patient is incontinent. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap. Auditory hallucinations are associated with schizophrenia but havenot been described as the most debilitating handicap.
What is the primary goal that the nurse should establish for a patient with an open wound?
1) The wound will remain free of infection throughout the healing process.
2) Client completes antibiotic treatment as ordered.
3) The wound will remain free of scar tissue at healing.
4) Client increases caloric intake throughout the healing process
1) The wound will remain free of infection throughout the healing process.
Wounds healing by secondary intention are more prone to infection; therefore, the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake
The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient?
1) Encouraging family members to visit only during the day
2) Applying wrist restraints during periods of agitation
3) Playing soft, calming music during the evening
4) Administering lorazepam (a tranquilizer)
3) Playing soft, calming music during the evening
Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.
Stage 3 Wound
What are the states of awareness?
- Alert: patient is awake and aware of the environment and themselves, they are speaking clearly and making contact.
- Confused: actions and speech are inappropriate
- Lethargic: speech and mental processes are slow or sluggish
- Obtunded: low level of awareness and response to environment
- Stuporous: patient can be aroused by vigorous stimulation but seems confused during periods of arousal
- Comatose: no spontaneous movement, no verbalization, and only nonpurposeful movement with stimulation
The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?
1) Do nothing; this is normal postoperative urine output.
2) Increase the infusion rate of the patients IV fluids.
3) Notify the provider about the patients oliguria.
4) Administer the patients routine diuretic dose early.
Notify the provider about the patients oliguria.
While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?
Serosanguineous
Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds.
A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload?
1) Administering albuterol (a central nervous stimulant) as needed
2) Administering a tranquilizer intravenously every 2 hours as prescribed
3) Delivering oxygen at 6 L/min via nasal cannula
4) Maintaining complete bedrest in a quiet, dimly lit room
Administering albuterol (a central nervous stimulant) as needed
Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient to relax, thus preventing sensory overload. If the patients oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone.
Stage 1 wound
Nursing interventions for delirium
a. Wear name tags, stay with consistent caretakers, identify places/dates/times to reorient, speak clearly and calmly, encourage family to visit, eliminate unnecessary noise, schedule activities, provide adequate sleep, adequate pain management
Which older adult is experiencing normal aging changes of the urinary system?
1) A man who has difficulty voiding, especially when starting his stream
2) A woman who wakes up to void once during the night
3) A man who has difficulty getting a hard erection
4) A man who says he has burning when he urinates
2 and 3
Because of changes in bladder capacity and changes in blood flow to the kidneys, many older adults wake at least once during the night to void. Sexual response changes are also normal; it is common for older adult men to have less firm erections. A man who has difficulty starting his urine stream and voiding likely has an enlarged prostate, which is physiologically not normal. Burning on urination is indicative of a bladder infection and is not normal.
Pressure ulcers are directly caused by which of the following conditions at the site?
Compromised blood flow
Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.
For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Choose all that apply
1) Talk to the patient as you provide care.
2) Incorporate more touch in the plan of care.
3) Give frequent eye care if blink reflex is absent.
4) Keep the side rails up and bed in low position
3 and 4
Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the side rails up. If the patients blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure.
Stage 2 Wound
What is a neobladder?
New bladder usually made from small bowel