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Nurse Exam 4
| Question | Answer |
|---|---|
| What are the main structures of the Urinary tract? | Kidneys, Ureters, Bladder, and Urethra |
| A normal health person general excretes how much urine daily? | 1500-2000mL/day |
| The purpose of the nephrons are to: | perform most of the functions filtration and elimination |
| The normal range for urine in the bladder is between? | 150-200 mL |
| Interventions such as ___, ___, and ___ ___ may affect a client's urinary elimination. | surgery, immobility, and therapeutic diet |
| A temporary or permanent stoma for the drainage of urine is: | urinary diversion |
| This type of Urinary diversion has one or both ureters to the abdominal surface | Ureterostomy |
| This type of urinary diversion has a tube from the renal pelvis to the abdominal surface | Nephrostomy |
| Urinary diversion may be created for clients who have ___ or ___ to the bladder | cancer, injury |
| Full bladder control is normal around what age? | 4-5 years |
| What problem after 40 years leads to urinary frequency, hesitancy, retention, incontinence, and UTI in men? | Enlargement of the prostate |
| Enlargement of the prostate after age 40 can lead to several problems including; | Urinary infrequency, hesitancy, retention, incontinence, and UTI |
| What things put women at higher risk for prolapse of the bladder, which leads to stress incontinence | Childbirth and gravity |
| Childbirth and gravity weaken the pelvic floor, putting clients at risk for the prolapse of the bladder, leading to stress incontinence, which can be managed with; | pelvic floor exercises (Kegel) |
| In the elderly what normal aging symptoms can lead to difficulty with urine elimination | -Have few nephrons -Loss of muscle tone of the bladder -inefficient emptying of the bladder Increase in the incident of nocturia |
| Inefficient emptying of the bladder can increase the risk for; | UTI |
| Although the frequency results from a loss of muscle tone in the bladder, Incontinence is not associated with normal aging, only ___ or ___ impairment | neurological or mobility impairment |
| During Pregnancy there is a ___ to ___ increase in ___ volume, which increase ___ workload and output. | 30-50%, circulatory, renal |
| What hormone causes relaxation of the urinary sphincter/ | relaxin |
| An increase in sodium leads to ___ urination | decreased |
| An increase in ___ leads to decreased urination | sodium |
| ___ and ___ increase urination | Caffeine and alcohol |
| Caffeine and alcohol intake ___ urination | increase |
| Factors Affecting Normal Urinary Elimination | Age Pregnancy |
| Factors Affecting Normal Urinary Elimination | Diet poor abdominal and pelvic muscle tone |
| Factors Affecting Normal Urinary Elimination | Acute and chronic disease conditions Spinal cord injuries |
| Factors Affecting Normal Urinary Elimination | Immobility Psychosocial factors |
| Factors Affecting Normal Urinary Elimination | Pain Surgical Procedures |
| Factors Affecting Normal Urinary Elimination | Medications |
| Psychosocial factors that may effect urinary elimination include; | Emotional stress and anxiety Public bathrooms, lack of privacy Not having enough time (predetermined breaks) |
| pain factors affecting normal urinary elimination can arise due to: | Suspension of urge due to urinary tract pain, Ureter obstruction to renal colic, Arthritis or joint pain due to immobility leading to microurition |
| Surgical procedures can affect normal urinary elimation how? | Alteration in the glomerular filtration rate from anesthesia/opioid analgesics, which results in decreased urinary output --OR-- Lower abdominal surgery creating obstructing edema and inflammation |
| Surgical procedures can affect normal urinary elimation how? | Lower abdominal surgery creating obstructing edema and inflammation --OR-- Alteration in the glomerular filtration rate from anesthesia/opioid analgesics, which results in decreased urinary output |
| How can medication affect normal urinary elimination? | Diuretics ---OR--- Antihistamines and anticholinergics --OR-- medication that change the urine colors --OR-- chemotherapy |
| What are some medication that will change the color of urine? | Pyridium (orange) --OR-- Amitriptyline (green/blue --OR-- levodopa (brown/black) |
| What medication might turn the urine orange? | Pyridium |
| What medication might turn the urine blue/green | Ampitriptyline |
| What medication might turn urine brown/black | levodopa (Dopar) |
| Diuretic may affect normal urinary elimination why? | Diuretics prevent reabsorption of water |
| Antihistamines and anticholinergics may affect normal urinary elimination why: | they cause urinary retention |
| This diagnostic test uses a portable ultrasound scanner noninvasively measures bladder volume to measure residual volume after voiding. | Bedside sonography/bladder scanner |
| This diagnostic test uses an x-ray to determine the size, shape, and positon of the kidneys | KUB ((kidney, ureters, bladder) |
| This diagnostic test a Iodine contrast to view ducts, renal pelvis, ureters, bladder, and urethra. | IVP (intravenous pyelogram) |
| This diagnostic test needs to be avoided if the client has allergies to iodine or shellfish? | IVP (intravenous pyelogram) |
| This diagnostic test views the gross renal structures | Renal Ultrasound |
| This diagnostic test is used to view renal bloodflow and anatomy of the kidney and does NOT use a contrast | Renal Scan |
| This diagnostic test uses an endoscope to visualize the bladder and urethra | Cytoscopy |
| This diagnostic test is used for testing bladder muscle function by filling the bladder with CO2 or 0.9% Sodium Chloride and comparing pressure readings with the reading s with the clients reported sensation | Ultradynamic testing |
| Correct size and type for a child needing a catheter would be | 8-10 Fr |
| Correct size and type for a woman needing a catheter would be | 14-16 Fr |
| Correct size and type for a man needing a catheter would be | 16-18 Fr |
| Catheter tubing is generally made from: | Teflon or Silicon |
| Most UTI infections are caused by what bacteria? | E.Coli |
| This factor is due to close proximity of the the urethral meatus in woman to the anus | Factors that increase the risk of UTI's |
| This factor is due to frequent sexual intercourse | Factors that increase the risk of UTI's |
| This factor is due to menopause decreasing estrogen levels and increasing susceptibility | Factors that increase the risk of UTI's |
| This factor is due to Uncircumcised Males | Factors the increase the risk of UTI's |
| This factor is due to the use of indwelling catheters | Factors that increase the risk of UTI's |
| Nursing implications for UTI prevention include what three things: | Cleanse female patients from back to front--- Cleanse beneath the foreskin of males--- Provide regular catheter care |
| A client with an indwelling catheter reports a need to urinate; What intervention should the nurse perform? | Check the patency of the catheter |
| When collecting a 24 hour urine specimen what intervention should the nurse follow? | Discard the first voiding |
| Which position promotes normal elimination? | Sitting |
| Factors affecting normal Bowel elimination would include: | Age---Diet--- Fluids--- Physical Activity --- Psychological Factors--- Personal Habits --- Positioning--- Pain--- Pregnancy--- Surgery and Anesthesia --- Medications |
| Bowel movement that are infrequent, hard or dry, and difficult to pass | Constipation |
| An increased number of loose, liquid stool | Diarrhea |
| When examping the stool of an infant what would you expect to find: | Breast Milk- watery and yellow brown stool Formula- pasty and brown |
| At around what age do Toddlers develop bowel control? | 2-3 years |
| What factors of aging might affect normal bowel elimination for an older adult? | decreased peristalisis--- relaxation of the sphincters |
| Fiber requirement to reduce factors affecting normal bowel elimination is around? | 25-30g/day |
| Dietary factors that affect normal bowel elimination can include: | Not getting enough fiber--- Lactose intolerence (difficulty digesting milk products) |
| Normal fluid intake from fluid and food sources in order to promote normal bowel elimination is around: | 2000 - 3000 mL/day |
| How can physical activity affect normal bowel elimination? | It stimulates intestinal activity |
| Psychosocial factors such as Emotional distress can effect normal bowel elimination how? | Increases peristalisis and exacerbates chronic conditions |
| Emotional distress can increase peristalisis and exacerbates chronic conditions such as: | Colitis--- Crohn's Disease--- Ulcers--- Irritable bowel syndrome |
| Psychosocial factors such as Depression can affect normal bowel elimination how? | Decreases peristalisis leading to constipation |
| Personal habits factors that can affect normal bowel elimination including: | Use of public toilets--- "One-a-day" attitude towards bowel elimination--- lack of privacy |
| Positioning problems affecting normal bowel elimination include: | Immobilization (which makes defecating difficult) |
| How can Pain affect the normal bowel elimination: | Discomfort leads to suprresion of the urge to defecate--- Opioid medications can lead to constipation |
| How can Pregnancy effect the normal bowel elimination: | Growing fetus comprimises intestinal space--- Slower peristalisis--- Straining increases the risk of hemorrhoids |
| How does Surgery and anesthesia affect normal bowel elimination: | Temporarily slows intestinal activity--- Paralytic ileus |
| When caring for a patient who has recently return from surgery what should be considered before advancing the clients diet/ | Evaluate for paralytic ileus (must ausculate for bowel sounds) |
| How can medications affect normal bowel elimination: | Laxatives (soften the stool)--- Cathartics (promotes peristalisis --- Laxative abuse leading to dehydration and diarrhea |
| Visual Diagnostic test of the bowel that views the large colon and sometimes portions of the lower small bowel and may biopsied | Colonoscopy |
| A visual diagnostic test that is used to view the sigmoid colon and rectem and may be biopsied | Sigmoidscopy |
| Commonly used Preperations used for visual diagnostic tests include: | NPO for 12 hours prior to procedure--- clear fluids only 24hrs prior to procedure --- Bowel prep using laxatives--- use of moderate sedation using a benzodiazepine and an opioid.--- Client not permitted to drive home after procedure |
| Signs and symptoms include bowel patterns of difficult and infrequent evacuation of hard, dry feces | Constipation |
| This may result from improper diet, decreased fluid intake, lack of exercise, or side effects of certain medications. | Constipation |
| Before the use of laxatives for constipation are used what should be tried: | Increasing fiber and water consumption |
| What product is generally used before stool softners, stimulants, or suppositories to promote bowel elimination. | Bulk-forming products |
| What is consider the last resort for stimulating defecation: | Enemas |
| The signs and symptoms are stool that is wedged into the rectum with diarrhea fluid leaking around the impacted stool | Impaction |
| When treating this digital removal of the stool is done using a gloved and lubricated finger | Impaction |
| When treating this the stool is looseded aroud the edges and then removed in small pieces, allowing the client to rest as necessary: | Impaction |
| When evacuating the rectum what should you be careful of doing? | Stimulating the vagus nerve |
| Signs and symptoms of this include frequent, liquid stools caused by various disorders. | Diarrhea |
| For this the cause may be determined and treated | Diarrhea |
| For this medication may be prescribed which will slow down peristalsis | Diarrhea |
| For this providing good perineal care after each stool and applying a moisture barrier would be important | diarrhea |
| Inability to control defectation, often caused by diarrhea, or also medications, infections, or impaction | Fecal incontinence |
| The signs and symptoms are the distention of the bowel from gas accumulation (May cause cramping or feeling fullness) | Flatulence |
| A good way to encourage the passing of flatulence would be too | walking (ambulating) |
| The signs and symptoms are engorged, dilated blood vessels in the rectal wall caused by difficult defectation, pregnancy, liver disease, and heart failure | Hemorrhoids |
| These may be itchy, painful, and bloody after defectation | Hemorrhoids |
| When cleaning these moist wipes may be more comfortable | Hemorrhoids |
| For these sometimes application of prescribed ointments or creams may help | Hemorrhoids |
| Viral gastroenteritis may cause: | diarrhea |
| Bacteria gastroenteritis may cause: | diarrhea |
| Overuse of laxatives and Use of certain antibiotics may cause: | diarrhea |
| Inflammatory bowel disease and Irratable bowel syndrome may cause: | diarrhea |
| Food born pathogens may be a cause for: | diarrhea |
| When monitoring for signs and symptoms of constipation what will you observe for: | Abdominal Bloating--- Abdominal cramping---Straining at defecation |
| When monitoring for signs and symptoms of diarrhea what will you observe for: | Signs and symptoms of dehydration--- Frequent loose stools--- Abdominal cramping |
| The order of the small intestine is: | Duodenum Jejunum Ileum |
| The order of the large intestine is: | Cecum Ascending Transverse Descending Sigmoid |
| Sensory Perception is the ability to recieve and interpret sensory perceptions such as: | Consciousness---Arousal and awareness---Memory---Affect---Judgement---Awareness of reality---Language |
| This is a change in reception and/or perception | sensory deficits |
| This is a reduced sensory input either from the internal or the external environment. | Sensory deprivation |
| This can affect any of the senses and usually the body will try and compenstae for the deficit. | Sensory defecit |
| This can result from an illness, trauma or isolation. | Sensory deprivation |
| This is excessive, sustained, and unmanageable multisensory stimulation | Sensory Overlaod |
| presbyopia, cataracts, and glaucoma all all factors that can contribute to what? | vision loss |
| diabetic retinopathy, macular degeneration, and infections are all factors that can contribute to what? | vision loss |
| Inflammation, injury and brain tumors are all factors that can contribute to what? | vision loss |
| Obstruction, tympanic membrane perferation, ear infections and otosclerosis are all facots that can contribute to what? | conductive hearing loss |
| Exposure to loud noises, ototoxic medications, aging, and acoustic neuromas are all factors that can contribute to what? | sensorineural hearing loss |
| A form of nonverbal communication that helps to clarify verbal communication to clients is ___ | gestures |
| ___ means that client cannot speak or comprehend spoken language. | Aphasia |
| A client whose sensory input is reduced may experience sensory ___ | deprivation |
| A conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, nervous pathways, and the brain | Sensory Perception |
| When a person is unable to process or manage the intensity or quantity of incoming sensory stimuli | Sensory overload |
| A lessening or lack of meaningful stimuli, monotonous sensory input, or an interference with the processing of information | Sensory deprivation |
| Systematic way a person thinks, reasons, and uses language | Cognition |
| Memory, comprehension and concentration | Intelligence |
| A process of sorting, organizing, categorizing information | Thinking |
| A process of receiving and interpreting sensory stimuli | Perceiving |
| Concentrating on a specific stimulus without being distracted | Attending |
| Cognitive Patterns of thinking include: | Thinking---Perceiving---Attending---learning---remembering---Communicating |
| A process of acquiring knowledge that depends on abstract | Learning |
| This depends on perceived value | Remembering |
| Spoken or written language | Communicating |
| Blood Flow, Nutrition, and Metabolism are all factors of what: | Factors affecting Cognitive function |
| Fluid and Electrolyte Balance,Sleep and Rest, Self-Concept are all factors of what: | Factors affecting Cognitive function |
| Onset: insidious Duration: months Course: stable Awareness: normal Alertness: normal Orientation: varies | Dementia |
| Onset: rapid Duration: hours Course: fluctuates Awareness: impaired Alertness: fluctuates Orientation: impaired | Confusion |
| Memory: recent and remote Thinking: poor Perception: normal Sleep-wake cycle: fragmented Physical illness or drug toxicity: absent | Dementia |
| Memory: impaired Thinking: disorganized Perception: hallucination Sleep-wake cycle: disrupted Physical illness or drug toxicity: either or both | Confusion |
| A disturbed thought processes | Disorganized Thinking |
| acutely aware of environment | Hypervigilant |
| aware of incoming stimuli | Alert |
| not fully awake | Lethargic |
| difficult to arouse | Obtunded |
| completely unresponsive | Comatose |
| cognitive impairment | Delirium |
| increased confusion or agitation at end of day | Sundowner’s |
| persistent cognitive disease | Schizophrenia |
| Broca’s, knows what they want to say, but can’t | Expressive Aphasia |
| Wernicke’s, cannot understand | Receptive Aphasia |
| cannot recall words or names | Anomic Aphasia |
| speech is absent, comprehension reduced | Global Aphasia |
| distorted speech sounds | Dysarthria |
| A person who has damage to this part of the brain may have some sensory perception problems: | RAS (Reticular activating system) |
| RAS tell the brain how to: | act |
| What controls the following: Sensory, visceral, kinesthetic and cognitive | RAS (Reticular Activating System) |
| Normal visual sensory should be: | Visual 20/20, full field of vision, tricolor vision |
| Normal auditory sensory should be; | Normal hearing of sounds at 0-25 decibels, at frequencies of 125-8000 per second |
| Normal hearing of sounds at ___ ___ decibels, at frequencies of 125-8000 per second | 0-25 decibals |
| Auditory Normal hearing of sounds at 0-25 decibels, at frequencies of ___ ___ per second | 125-8000 per second |
| Normal Olfactory sense should be able to: | Discrimination of primary odors |
| Normal Gustatory senses should be able to: | discriminate sour, salty, sweet and bitter |
| Normal tactile sense should be able to: | Discrimination of touch, pressure, vibration, position, tickling, temperature, pain |
| State of optimum arousal – not too much, not too little | Sensoristasis |
| Disturbed Sensory Perception: Change in the amount or patterning of oncoming stimuli, accompanied by a diminished, exaggerated, distorted or impaired response to such stimuli (NANDA, 2005) | |
| Characteristics of normal cognitive thinking include: | Intelligence---Reality Perception--- Orientation to time, place, situation and self---Judgment---Recall and Recognition---Language |
| The normal functions of the intestines include: | Motility---Absorption---Defecation |
| What movement helps to propels contents along entire length of intestines | peristalisis |
| The intestinal function of Motility uses a combination of of movements to move material through the intestines: | peristalisis and segmentation |
| Autonomic nervous system affects the rate of: | motility |
| The rate of motility is affected by what: | Autonomic nervous system |
| The stimulation of this system slows peristalsis and delays passage | Sympathetic stimulation |
| The ___ system increases bowel motility and emptying | Parasympathetic |
| Most nutrients are absorbed in what part of the body: | duodenum and jejunum |
| Digestive function is where? | stomach |
| Absorption function is where? | intestine |
| Characteristics of normal feces is: | 75% water; 25% solid |
| The normal contents of feces includes: | Bacteria, indigested fiber, fat, inorganic matter and protein |
| Medications that may change normal bowel habits include: | Narcotics---iron---Laxatives---stool softeners---Antidiarrheals |
| Use of barium enema's may increase the risk for: | impactions |
| Excessive swallowing of air Produced by bacterial activity in large intestine Certain foods These are all things that can increase: | Flatulence |
| Demonstrate a normal pattern of bowel elimination without evidence of constipation, diarrhea, fecal incontinence, or distention | Nursing Outcome |
| Free of preventable complications or adverse consequences from altered bowel elimination | Nursing Outcome |
| Maintain and promote an acceptable pattern of bowel elimination | Nursing Outcome |
| Metamucil | Bulk Forming Medication |
| Emolients | Stool Softners |
| Saline | Milk of Mag |
| Stimulants | Castor oil, Dulcolax |
| Antidiarrheal agents include: | Absorbents---Bulk-forming agents---Opiates---Synthetic Opiates---Antispasmodics |
| Kaopectate, absorbs excess fluid and bowel irritants. This is an example of what type of antidiarrheal medication: | Absorbents |
| Psyllium, attracts water to absorb excess fluid. This is an example of what type of antidiarrheal medication: | Bulk forming agent |
| Paregoric or Imodium, ↓motility, ↑water & electrolyte absorption. This is an example of what type of antidiarrheal medication: | Opiates or synthetic opiates |
| Atropine, ↓motility (Tincture of belladonna). This is an example of what type of antidiarrheal medication: | Antispasmodics |
| Simethicone is an example of an: | Antiflatulence agents |
| Hypertonic, osmotically drawing water from colon to cause water retention in lower colon, increases peristalsis | small-volume enema |
| Contains mineral oil, that will soften stools | Oil retention |
| A cleansing enema, using about 1000mL of tap water, may also be used as a Soap Sud Enema. | Large volume enema |
| An enema used to help relieve flatus, using between 300-500mL of fluid. Instill and lower bag to withdraw | Return Flow enema |
| this is used to help to relieve gas and is left in place 15-20 minutes | Rectal tube insertion |
| Drains stomach and intestines of pressure caused by accumulation of GI air and fluid | Gastric decompression |
| The purpose of this is to help with Accidental poisoning, Inability to swallow, and with GI bleeding | Gastric Lavage |
| The purpose of this is to provide Enteral nutrition or gastric gavage | Gastric feeding |
| Never repostition of postoperative gastric tube | |
| Average amount of fluid lost per viod is between | 250-400 mL |
| A person with a ctahiter would have about how much urinary output per hour? | 30mL |
| Normal Urinary Pattern is between how many times a day: | 6-8/day |
| elimination of urine | Micturition |
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