Potter & Perry: Fundamentals of Nursing, 7th Edition

Study Guide Answer Key Chapter 1: Nursing Today 1. the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and populations. 2. the role of nursing as being in charge of a client’s health based on the knowledge of how to put the body in such a state as to be free of disease or to recover from disease. 3. d 4. c 5. b 6. a 7. Demographic changes (rural areas to urban centers, increased life span, higher incidence of chronic long-term illness, increased incidence of alcoholism and lung cancer). Women’s health care issues (new specialties). Human rights movement (minorities, terminal illness, pregnant women, older adults). Medically underserved (poor and on Medicaid, working poor, mentally ill with little to no access to health care). Threat of bioterrorism (nuclear, chemical or biological). 8. Rising health care costs (challenge is to use health care and client resources wisely). Evidence-based practice (a problem-solving approach to clinical practice that uses the best available evidence along with your expertise and client preferences and values in making decisions about care). Nursing and biomedical research. Nursing shortage (global). 9. A profession requires an extended education of its members as well as a basic liberal foundation. has a theoretical body of knowledge leading to defined skills, abilities, and norms. provides a specific service. has autonomy in decision making and practice has a code of ethics for practice 10. Assessment Diagnosis outcome identification planning implementation Evaluation 11. Quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, leadership

a. b. c. d. e. a. b. c. d. e.

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Study Guide Answer Key


12. the philosophical ideals of right and wrong that define the principles you will use to provide care to your clients 13. c 14. d 15. b 16. e 17. a 18. g 19. f 20. To protect public health, safety, and welfare 21. Novice, advanced beginner, competent, proficient, expert 22. b 23. d 24. n 25. g 26. c 27. f 28. m 29. i 30. k 31. j 32. l 33. h 34. e 35. a 36. o 37. 3. Nursing is a combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies. 38. 2. Candidates are eligible to take the NCLEX-RN to become registered nurses in the state in which they will practice. 39. 2. The ANA’s purpose is to improve the professional development and general welfare of nurses.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Study Guide Answer Key Chapter 2: The Health Care Delivery System


b f a e c d h g Primary care focuses on health services that are provided on an individual basis while primary health care focuses on improved health outcomes for an entire population. 10. work redesign 11. case management 12. The nurse coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care for the client. 13. Discharge planning 14. is a multidisciplinary treatment plan that shows what treatments or interventions clients need to have while in the hospital for a specific reason 15. a. safe and effective use of medications b. instruction and counseling on food-drug interactions, nutrition, and modified diets c. rehabilitation techniques d. access to appropriate community resources e. when and how to obtain further treatment f. the responsibilities of the client and the families with ongoing health care needs 16. is to help individuals regain maximal functional status and to enhance quality of life through promotion of independence and self-care 17. wound care, respiratory care, monitoring of vital signs, elimination care, nutrition, rehabilitation, monitoring compliance of medications, blood glucose monitoring 18. rehabilitation 19. extensive supportive care until they are able to move back into the community or into a residential-care facility 20. minimum data set (MDS), resident assessment protocols (RAPs), utilization guidelines of each state 21. d 22. c 23. a 24. b 25. the integration of best research evidence with clinical expertise and patient values 26. Quality improvement (QI) 27. nursing-sensitive outcomes 28. a. respect values, preferences, and needs

1. 2. 3. 4. 5. 6. 7. 8. 9.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

an affiliate of Elsevier Inc. rehabilitation helps to maximize the client’s level of independence. not curative treatment Mosby items and derived items © 2009. initially focuses on the prevention of complications related to the illness or injury. . emotional support f. 2. physical comfort e. Activities that develop human attitudes and behaviors to maintain or enhance wellbeing 30. communication.. Inc. coordination and integration of care c. Once the condition stabilizes. where they receive supportive care until they are able to move back into the community 32. 31.Study Guide Answer Key 4 b. 2005 by Mosby. involvement of family and friends g. 1. transition and continuity 29. 1. and education d. focus is palliative care. information. 4.

who have limits in access to health care services c. communicable diseases. have multiple stressors 9. an affiliate of Elsevier Inc. criminal convictions. clients who are more likely to develop health problems as a result of excess risks b. MVAs by teenage drivers 3. are dependent on others for care 7. knowing the contributions of each profession. adolescent pregnancy rates. access to health care is limited because of lack of benefits. assists clients in identifying and clarifying health problems and in choosing appropriate courses of action 19. a. and family breakdown 11. and groups in the community 4. resources. lack the ability to maintain employment or to care for themselves 12. families. .g. eat less nutritious foods. a. live in hazardous environments. focuses on primary rather than institutional or acute care and provides knowledge about health and health promotion and models of care to the community 2. mental health problems. dysfunctional relationships 10. the inner circle of the client and the family b. assumes responsibility for the case management of multiple clients 15. often is the one who presents the client’s point of view to obtain appropriate resources 17. Inc. people and settings that have frequent contact with the client and family c. acts to empower individuals and their families to creatively solve problems or become instrumental in creating change within a health care agency 16. is essential for exploring client issues. socioeconomic stressors.. and developing a plan of care 18. local communities’ values and policies d. focus requires understanding the needs of a population (e. substance abuse.Study Guide Answer Key Chapter 3: Community-Based Nursing Practice 5 1. a. with the primary focus on the health care of individuals. is a nursing practice in the community. homeless or live in poverty. larger social systems 6. where the focus is on the needs of the individual or family 5. language barriers. in community settings such as the home or a clinic. suffer from chronic diseases. socioeconomic problems result from financial strain of the cost of drugs. have a greater demand for health care services 13. together with the family you develop a caring partnership to recognize actual and potential health care needs and identify community resources 14. or cultural groups) b. older adults. 2005 by Mosby. work at high-risk jobs. gathering information on incident rates for identifying and reporting if new infections or diseases. and transportation 8. high-risk infants.. clarifying roles. goal is to help clients assume the skills and knowledge needed to care for themselves Mosby items and derived items © 2009.

location of services. the coordinating of activities of multiple providers and payers in different settings throughout a client’s continuum of care 25. and tracking incident rates 21. 2005 by Mosby. a. social (education and communication systems. government. an affiliate of Elsevier Inc.. growth trends. 6 structure (geographical boundaries. ethnic and religious groups) c. . education level. welfare system) 22. 23. 3. 3. economic population (age and sex distribution. health teaching. status) b. housing. 4. Inc. observe the community’s design. 24. emergency services.Study Guide Answer Key 20. it is important to focus on the individual and family and respect and incorporate the values of the community. and locations where the residents meet Mosby items and derived items © 2009. Because nurses provide direct care services where clients live and work. volunteer programs. They are usually jobless and do not have the advantage of shelter and cope with finding a place to sleep at night and finding food. 3. may be involved in case finding.

and sexual love) d. d 11. 2005 by Mosby. g 23. ethics. . and dimensionality) aid in the development of principles related to human development. a 10. and health policy Mosby items and derived items © 2009. social relationships.Study Guide Answer Key Chapter 4: Theoretical Foundations of Nursing Practice 7 1. g 16. F 27. pattern and organization. biobehavioral sciences. a person interacts with the environment. an affiliate of Elsevier Inc.. j 14. 19. and perceive the world. 3. 4. 32. physical sciences. 18. f 5. usefulness. c 2. f 9. d 3. 4. h 12. C 25. As an open system. self-actualization 20. b 17. basic social sciences. I 24. c 15. Nurses needing to know all about the disease process were early attempts to differentiate between nursing and medicine. A 29. water. Inc. e 4. a. reason. safety and security needs (physical and psychological) c. and self-worth) e. 31. a 6. physiological needs (air. openness. Neuman defines a total-person model of holism and an open-systems approach. B 26. nursing science. i 13. H 28. Piaget’s theory of cognitive development helps to explain how children think. achievement. 30. b 7. e 22. d 21. food) b. The 4 dimensions (energy fields. 2. esteem and self-esteem needs (self-confidence. e 8. love and belonging needs (friends.

the health alteration. b. the author will explain the clinical implications for the topic presented. clinical practice guidelines. is research designed to assess and document the effectiveness of health care services and interventions Mosby items and derived items © 2009. a detailed background of the level of science or clinical information that exists about the topic of the article 11. and use resources effectively 16. and values in making a practice decision e. quality improvement data. use the evidence you find as a rationale for an intervention you plan to try. systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific client population 7. 15. integrate all the evidence with one’s clinical expertise. 8. O = outcome 4. contains information about its purpose and the importance of the topic for the reader 10. the author will detail the results of the study and explain whether a hypothesis is proven or how a research question is answered. or a new therapy or technology. how clients are affected. or design. P = patient/population of interest b. existing clinical practice guidelines. methods. policies and procedures. improve professional education and practice. Inc. agency policy and procedure manuals. 2005 by Mosby. A research article will include a section that explains if the findings from the study have clinical implications. client preferences. In a research article. and values in making decisions about client care 2. means that a panel of experts familiar with the article’s topic or subject matter has reviewed the article 6. In a clinical article. or computerized databases 5.. such as teaching tools. C = comparison of interest d. . I = intervention of interest c. is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician’s expertise. an affiliate of Elsevier Inc. A clinical article can contain a description of the population. summarizes the purpose of the study or clinical query. Controlled trials without randomization are studies that test interventions. a. 12. collect the most relevant evidence c. a. and the implications for nursing practice 9. A research article contains a purpose statement. evaluate the practice decision 3. client preferences. clinically appraise the evidence d. 14. apply the research in your plan of care for a client. is a way to identify new knowledge. the major themes or findings. ask a clinical question. 13. new tools.Study Guide Answer Key Chapter 5: Evidence-Based Practice 8 1. but researchers have not randomized the subjects into the control or treatment groups.

involves the description and interpretation of cultural behavior b. identify the problem area to be studied b. reliable. . 4. the conditions are tightly controlled to eliminate bias and to ensure that findings can be generalizable to similar subjects 20. The results of other studies are not presented. an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others 26. and generalizable to subjects 18. obtain information from populations regarding the frequency. 28. identify the area of interest or clinical problem b. it involves finding out how well a program. systemically developed statements about a plan of care for a specific set of clinical circumstances involving a specific client population Mosby items and derived items © 2009. distribution. a. practice. a. recruit subjects. an affiliate of Elsevier Inc. 29. with a focus on what people experience in regard to daily practices or experiences and how they interpret those experiences c. or policy is working 22. analyze the results of the study e. design the study protocol c. procedure. The summary details the results of the study and explains whether a hypothesis is supported. obtain necessary approvals. 27. the abstract and introduction tell you if the topic of the article is similar to your PICO question or related closely enough to provide you with useful information. Inc. is a systematic step-by-step process that ensures that the findings from a study are valid. 3. 3.Study Guide Answer Key 9 17. goal is to understand the phenomena 19. and interrelation of variables among the subjects 21. involves inductive reasoning to develop generalizations or theories from specific observations or interviews 23. a. The organization evaluates and analyzes current performance to use results to develop focused improvement actions. and implement the study d.. control external factors that may influence a relationship between the phenomena that are being studied d. formulate recommendations for future research 25. 2005 by Mosby. Together. is a method of collecting and analyzing data with the aim of developing theories and propositions that are grounded in the real world 24. empirical data is gathered e. steps of planning occur in an orderly fashion c.

behavior-specific knowledge and affect c. lifestyle habits. a. prevent and reduce disease and disorders 4. psychosocial variables: the stability of the person’s marital or intimate relationship. an affiliate of Elsevier Inc. The clients are the ultimate experts regarding their own health. a. 2005 by Mosby. a. mental. behavioral outcomes 8. intellectual background (shaped by the person’s knowledge or lack of knowledge or incorrect information) c. individual’s perception of the seriousness of the illness c. spiritual factors (values and beliefs exercised by the patient) 10. Activities such as routine exercise and good nutrition help clients maintain or enhance their present levels of health. depression. and one should respect clients’ subjective experience as relevant in maintaining health or assisting in healing 9. values. Mosby items and derived items © 2009. 5. their approach to the system. promote healthy behaviors b. and social well-being. a. or regaining good health and preventing illness Negative: practices that actually or potentially are harmful to health 6. Different attitudes about illness cause people to react in different ways to the illness of a family member. . to increase quality and years of healthy life b. promote healthy and safe communities c.Study Guide Answer Key Chapter 6: Health and Wellness 10 1. Inc. emotional (the degree of stress. a. family practice: the way in which clients’ families use health care services generally affects their health practices b. the individual characteristics and experiences b. developmental stage (finding the patterns or general principles that apply to most people most of the time.. to eliminate health disparities 3. attaining. and occupational environment c. fear) e. the likelihood that a person will take preventative action 7. individual’s perception of susceptibility to an illness b. Positive: activities related to maintaining. a state of complete physical. 2. the concept of illness is dependent on the developmental stage of the individual) b. influences beliefs. perception of functioning (subjective data about the way clients perceive their physical functioning) d. and the nurse-client relationship 11. improve systems for personal and public health d. a. and customs that will influence their personal health practices.

the reaction of others to it. overweight) 18.. developmental or intellectual condition. social or environmental condition.. individuals gain from the activities of others without acting themselves b. a. and the variables of the illness behavior Mosby items and derived items © 2009. heart disease. is true prevention. activities that motivate people to avoid declines in health or functional levels 14. symptoms appear abruptly. is any situation. cultural background. Inc. sustained change over time 19. intellectual. their perceptions of symptoms and the nature of their illness--a person experiencing chest pain in the middle of the night seeking assistance b. habit. usually lasts longer than 6 months. economic variables. a. emotional. occurs when a defect or disability is permanent and irreversible. habits that have risk factors (sunbathing. heart disease. considering a change within the next 6 months c. usually has a short duration and is severe. social.Study Guide Answer Key 11 12. kidney disease or mental illness b. not intending to make changes within the next 6 months b. and social support 23. take remedial actions. and cancer with increased age c. depend on the nature of the illness. and use the health care system 22. accessibility of the system. cancer. a. diabetes mellitus. it involves minimizing the effects of the illness or disability 16. a. can also affect functioning in any dimension 21. actively engaged in strategies to change behavior e. industrial workers and the risk of cancer d. or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident 17. a. . define and interpret their symptoms. how people monitor their bodies. the client’s attitude toward it. premature infant. a. strategies that are designed to help persons achieve new understanding and control over their lives 13. social group. an affiliate of Elsevier Inc. physiological or psychological condition. pregnant or overweight. are intense. the visibility of symptoms. individuals are motivated to adopt specific health programs 15. a state in which a person’s physical. it precedes disease b. 2005 by Mosby. a. and often subside after a relatively short period b. focuses on the individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions c. developmental. making small changes in preparation for a change in the next month d. or spiritual functioning is diminished or impaired compared with the previous experience 20.

makes decisions. habit. Inc. role reversal can lead to stress.. and copes with everyday changes and challenges 24. Internal variables include all of the ones cited. or direct conflict over decision making e. gives support to individual members. depends in part on body image and roles but also includes other aspects of psychology and spirituality d. 12 reaction to the changes in body image depend on the type of changes. conflicting responsibilities for the adult or child. . take action. 25. 27. beliefs. or social or environmental condition that increases the vulnerability of the individual to an illness 26. 4. 1. is the process by which the family functions. and the support services available c. 2005 by Mosby. and use the health care system. The health belief model helps nurses understand factors influencing clients’ perceptions. and behavior. the rate at which changes takes place. an affiliate of Elsevier Inc.Study Guide Answer Key b. Mosby items and derived items © 2009. their adaptive capacity. 1. define and interpret their symptoms. Illness behavior involves how people monitor their bodies. any situation. 2.

treatment for the cancer or the cancer itself can cause pain and neuropathy d. retirement residences. energy-consuming anxiety b. osteoporosis.. every family member’s role. and fertility. and struggle to maintain core functions. inability to forgive c. . fixed income. and less social and who lack emotional support are at high risk for PTSD. 13 a. genetic or other susceptibility. low-income. sterility. isolated from social supports 5. Reinforce their health care provider’s explanations of the risks related to their cancer and treatment. intimacy. due to cancer treatment. 2005 by Mosby. find themselves ill-prepared to deal with the diagnosis. and sleep disturbances leading to depression b. Females who are young. an affiliate of Elsevier Inc. limitations of Medicare reimbursement. Inc. or shortness of breath? How distressed are you feeling at this point on a scale of 0-10? How do you think your family is doing with the cancer? If you have had sexual changes. difficulty sleeping. and the ability to think about and plan for the future b. sexual development. pulling in the arm or axilla. including chemotherapy or biotherapy. what they need to self-monitor. added job responsibilities for the spouse. a client’s body image or altered sexual function 4. is a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation. employment opportunities are affected. or an interaction between treatment and susceptibility b. and what to discuss with health care providers in the future. 7. and hot flashes 3. congestive heart failure. a. paresthesias. struggle with interpersonal problemsolving. sleeplessness. and hearing loss c. Caregivers report a lower quality of life than that of their other family members. fatigue. plans. a. and abilities change. changes in sexuality. Some examples may be: Have you had any pain or discomfort in the area where you had surgery or radiation? Are you experiencing fatigue. c. in systemic cancer treatment. long-term fatigue. maturational losses e. low self-esteem d. amenorrhea. there are generalized. diabetes. alters a young person’s social skills. what strategies have you tried to make things better? 8. tightness. a. impaired immune function. less educated. subtle effects ranging from small deficits in information processing to acute delirium 2. body image. associated sleep disturbances are the most frequent and disturbing complaints e. Mosby items and derived items © 2009. retire prematurely.Study Guide Answer Key Chapter 7: Caring for the Cancer Survivor 1. range along a continuum from sadness to disabling depression. numbness in the chest wall or axilla. economic burdens c. mental illness 6.

2005 by Mosby. or second cancers c. surveillance for cancer spread. intervention for consequences of cancer and its treatments d. 10. . an affiliate of Elsevier Inc. 4. prevention and detection of new cancers and recurrent cancer b. 14 Mosby items and derived items © 2009. 11. Inc. Many older adults have very limited Medicare reimbursement. 12. Coordination should be between the specialists and the primary care providers for ongoing clinical care. Cognitive changes can occur during all phases of the cancer experience. from small deficits in information processing to acute delirium. a. recurrence. Review survivorship care plan with client at time of discharge. 4.. 2.Study Guide Answer Key 9.

and inner harmony. humanity. striving to understand an event as it has meaning in the life of the other b. 2. used to protect the nurse and/or client. 5.Study Guide Answer Key Chapter 8: Caring in Nursing Practice 15 1. for better or worse. the nurse as the client’s advocate. and behave in relation to one another. solving ethical dilemmas by attending to relationships and by giving priority to each client’s unique personhood. being emotionally present to the other c. being honest advocate for the client’s care preferences giving clear explanations keeping family members informed make the patient comfortable showing interest in answering questions honestly Mosby items and derived items © 2009. taking in what a client says. and preserve a person’s dignity. e. enhance. unifying. doing for the other as he or she would do for the self if it were at all possible d. c. or spiritual resources d. symptoms. . a. a. a. 2005 by Mosby. and improves reality orientation c. as well as an interpretation and understanding of what the client is saying and giving back that understanding to the person who is speaking. 8. 7. b. an affiliate of Elsevier Inc. the concept of care as the essence and central.. The relationship influences both the nurse and the client. 4. or emotions that is acceptable c. emotional. Presence involves being there and being with. the skillful and gentle performance of a nursing procedure conveys security and a sense of competence b. 3. facilitating the other’s passage through life transitions e. person-to-person encounter that conveys a closeness and a sense of caring. wholeness. a form of nonverbal communication. and dominant domain that distinguishes nursing from other health disciplines. It looks for deeper sources of inner healing to protect. enhances self-esteem. feel. finding an interpretation or understanding of illness. Inc. which successfully influences the client’s comfort and security. mobilizing hope for the client and for the nurse b. it can be positive or negatively viewed 9. when performing a task or a procedure. recognizing that caring relationships connect us in a human-to-human. assisting the client using social. a. sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning 6. d. a connection between the one cared for and the one caring. Care is the essential human need and is necessary for the health and survival of all individuals. looks beyond the client’s disease and its treatment by conventional means. spiritto-spirit way 11. A universal phenomenon influencing the ways in which people think. 10. f.

. There is a mutual give-and-take that develops as nurse and client begin to know and care for one another. 13. Nurses are torn between the human caring model and the task-oriented biomedical model and the institutional demands that consume their practice. the expressions. and whether the family supports and delivers the therapies recommended Mosby items and derived items © 2009. 16. . 15. all nursing services will be available j. Inc. helping clients to do as much for themselves as possible k. teach the patient how to keep the relative physically comfortable 12. an affiliate of Elsevier Inc. 4. Listening involves paying attention to the individual’s words and the tone of his or her voice. client privacy i. their acceptance and understanding of therapies. provide necessary emergency care h. and patterns of caring vary among cultures. 3.Study Guide Answer Key 16 g. processes. 2. whether the interventions fit the family’s daily practices. 4. Even though human caring is a universal phenomenon. 2005 by Mosby. depends on the family’s willingness to share information about the client. 14.

Collectivistic groups often regard members of their ethnic groups as closest kin and want to consult them. Inc. 24. believe that an external agent. l 8. 27. 2005 by Mosby. and practices that are significant to their care that health care providers will take for granted unless otherwise uncovered 22. and practices of individuals. g 13. and life and death. Religious and spiritual beliefs are major influences on the client’s views about health. impersonal. . b 19. i 7. is a systematic and comprehensive examination of the cultural care values. the most common is the nuclear household made up of parents and their young children.Study Guide Answer Key Chapter 9: Culture and Ethnicity 17 1. certain genetic disorders are also linked with specific ethnic groups. Although different configurations of a family exist. f 5. and communities 21. 26. beliefs. d 6. Different cultural groups have distinct linguistic and communication patterns that reflect core cultural values. an affiliate of Elsevier Inc.. c 16. which can be human or nonhuman. c 2. h 4. d 20. j 10. families. 25. illness. b 12. e 3. m 9. causes health and illness 15. 23. and biological forces that cause alteration in the equilibrium of the human body b. aim is to encourage clients to describe values. a. Social hierarchy and roles are further defined by the culture. a 14. Mosby items and derived items © 2009. Differences exist in the dimensions of time that cultures emphasize and also in the manner of expressing time. beliefs. a 18. k 11. pain and suffering. knowledge of a client’s country of origin and its history and ecological contexts. Some distinct health risks are due to the ecological context of the culture. attribute illness to natural. Similarities shared by an immigrant group with the dominant culture in society are strong predictors of assimilation. e 17.

2005 by Mosby. an affiliate of Elsevier Inc. Nurses need to determine how much an individual’s life patterns are consistent with his or her heritage. respect for and about b. attention to details d. religious. . or modify client’s lifestyle 31. Inc. 29. retains and/or preserves relevant care values b. protection j. emphasizing mutual and reciprocal obligations of members. 1. Caring expressions integrate the central values and collectivistic active involvement of the group. 2. a. 2. comfort measures 30.. American culture (self-care ideology and individualism). touching k. 33. understanding h. concern for and about c. Due to the fact that different cultural groups have distinct linguistic and communication patterns Mosby items and derived items © 2009. Due to the changing demographic profile of the United States in relation to immigration and significant culturally diverse populations 34. reorder. connectedness i. a. change. adapt or negotiate with others for satisfying health outcomes c. helping and assisting e. and social groups 32. presence g. Involves racial. active listening f. 1. ethnic.Study Guide Answer Key 18 28.

and important developmental considerations 4. and learned family behavior. 11. Explain how the following examples impact the family 14. Alterantive patterns of relationships: multi-adult households. Family violence: emotional. Diversity: the uniqueness of each family unit. or when a single person decides to have or adopt a child 8. strengths.Study Guide Answer Key Chapter 10: Caring for Families 19 Define the three important attributes that characterize contemporary families 1. work and household schedules. skip-generation families and communal groups with children. Inc. Relative: those who have physical shelter but one that does not meet the standards of health and safety. 2005 by Mosby. Durability: is the intrafamilial system of support and structure that extends beyond the walls of the household 2. physical. . psychopathology. lifethreatening event that includes many stressors and may impact the family’s functioning and decision-making. especially among men who have sex with men. Extended family: includes relatives in addition to the nuclear family 7. 9.parent families are especially vulnerable. and single. Chronic: family patterns and interactions. Families at the lower end of the income scale have been particularly affected. Mosby items and derived items © 2009. Human immunodeficiency virus (HIV): While the epidemic has slowed. poverty. Trauma: Family members need to cope with the challenges of a severe. Resiliency: the ability of the family to cope with expected and unexpected stressors 3. 12. or as a social network with personally constructed ties and ideologies Current Trends and New Family Forms Summarize the various family forms 5. high-risk behaviors continue to rise. 15. social activities. and older adults across all social classes. Nuclear family: consists of the husband and the wife (and perhaps one or more children) 6. divorce. Homelessness: absolute: people without physical shelter who sleep outdoors in places that are not intended for human habitation. or desertion. joint living situation. nonfamilies. social isolation.. cohabiting partners and homosexual partners Explain the following threats and concerns facing the family 10. Acute and chronic illness: acute: family members are left in waiting rooms to anticipate information about their loved one. but the incomes have not increased. 13. economic resources must be reorganized around the illness or disability. and sexual abuse occurs toward spouses. children. an affiliate of Elsevier Inc. legally. Factors are complex and may include stress. Changing economic status: Two-income families have become the norm. A family is defined as: defined biologically. Single-parent family: one parent leaves the nuclear family because of death. each person has specific needs. Blended family: Parents bring unrelated children from prior or foster-parenting relationships into a new.

a. and use of internal and external resources 21. the better. . Explain the following attributes of healthy families. and practices influence health behaviors. Identify these process: communication among family members. caregiving. Identify the variables that affect the structure. Structure may enhance or detract from the family’s ability to respond to stressor. an affiliate of Elsevier Inc. Briefly explain each. family’s beliefs.Study Guide Answer Key 20 16. Developmental stages: Each stage has its own challenges. Theoretical Approaches: An Overview Summarize the following general perspectives when working with or studying families 17.. a. distribution of wealth greatly affects the capacity to maintain health. coping. support. Family as client: Family processes and relationships are the primary focus of nursing care. Mosby items and derived items © 2009. and presence are great. functions. assurance. nurturing. 2005 by Mosby. goal setting. and resources and includes tasks that need to be completed before the family is able to successfully move on to the next stage. Family functioning focuses on the processes used by the family to achieve its goals. integrity. hardinesss is the internal strengths and durability of the family unit b. 25. Need to focus on family patterns versus individual characteristics. 22. Attributes of Families 19. Family as context: The primary focus is on the health and development of an individual member existing within a specific environment. values. Rigid Structure: dictates who is able to accomplish a task and may limit the number of persons outside the immediate family who assumes these tasks b. End of life: The family’s need for information. resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events Family Nursing Identify the three levels and focuses proposed for family nursing practice. Family as system: Use both family as context and family as client simultaneously. and enactment of roles is overly flexible 20. and health 18. 23. Briefly explain each of the following. conflict resolution. developmental. Inc. The more you know about the family. Family health system: Interactive. needs. and health of a family: class and ethnicity (different life chances for its members). how they interact. 24. and their strengths and their weaknesses. Developmental stages: consistent patterns of behavior that lead to automatic action do not exist.

the following need to be addressed. May not recognize need for help or may not request help. Briefly explain. adaptability. Frequently tries to do it all. and job. Three factors underlie the family approach to the nursing process. Summarize the challenges for family nursing in relation to each of the following: a. Inc. Cultural diversity: in the family requires recognizing not only the diverse ethnic. a.. Identify areas to include in the family assessment: Interactive.Study Guide Answer Key 21 Nursing Process for the Family 26. that families have an impact on individuals c. children. Mosby items and derived items © 2009. . Family strengths: clear communication. Name them a. social emotional and spiritual well-being of the family unit and its members b. cultural. When implementing family-centered care. the nurse views all individuals within the family context b. Health promotion: improve or maintain the physical. Conflicting responsibilities for aging parents. 2005 by Mosby. that individuals have an impact on the families 27. an affiliate of Elsevier Inc. and health processes 28. support and nurturing among family members. and religious backgrounds of clients but also the differences and similarities within the same family 29. along with any shortcomings in the home setting b. spouse. coping. Restorative care: maintain client’s functional abilities within the context of the family. d. healthy child-rearing practices. as well as find ways to better the lives of the chronically ill and disabled Identify the conflicts that affect the “sandwich generation” 30. Acute care: challenges to the family in relation to early discharge and employment outside the home. and the use of crisis for growth c. Discharge planning: an accurate assessment of what will be needed for care at the time of discharge. developmental. integrity.

and the current social and historical context in which the individual is living Mosby items and derived items © 2009. a realization of mortality (50s) 15. Stage 5: (genital) time of turbulence when earlier sexual urges reawaken and are directed to an individual outside the family circle 4. Stage 3: (phallic) the genital organs become the focus of pleasure d. Contemporary Life-events approach considers: the individual’s personal circumstances.Study Guide Answer Key 22 Chapter 11: Developmental Theories 1. Stage 2: (anal) children become increasing aware of the pleasurable sensations of this body region with interest in the products of their effort c. Trust versus mistrust: Sensorimotor period 5. Fourth Theme: resignation and the belief that possibilities are limited (40s) 14. an affiliate of Elsevier Inc. Third Theme: the impact of a growing family and aging parents influences this time (late 30s) 13. 2005 by Mosby. emotions. egocentric 7. Industry versus inferiority: Conrete operations period 8. Biologic processes: produce changes in an individual’s physical growth and development b. Autonomy versus shame: Preoperational period 6. . this pattern is directed by gene activity 3. Identity versus role confusion: Formal operations period 9. Initiative versus guilt: Use of symbols. Fifth Theme: a decrease in negativism occurs. Inc. how the person views and adjusts to changes. Stage 1: (oral) sucking and oral satisfaction is not only vital to life. Explain the five psychosexual developmental stages of Freud’s theroy a. ability to understand and use language. 10. Briefly explain the following processes that affect growth and developement a. Socioemotional processes: consist of variations that occur in an individual’s personality. First Theme: the move away from parental influence is gradual as young adults establish themselves as adults (20s) 11. and relationships with others during their lifetime Developmental Theories 2. Cognitive processes: comprise changes in intelligence. Define temperament: is a behavioral style that affects the individual’s emotional interactions with others Gould’s research supports stage theory in adult development with a set of themes.. Briefly explain the five themes identified. Stage 4: (latency) sexual urges are repressed and channeled into productive activities that are socially acceptable e. Briefly summarize Gesell’s theory of development: is that although each child’s pattern if growth is unique. Second Theme: experience the consequences of the decisions of their independence (early 30s) 12. and the development of thinking c. but pleasurable b.

Level I: Preconventional level: The person reflects on moral reasoning based on personal gain. Explain the two stages of Piaget’s moral development theroy a. 17. Autonomous morality: child understands that people make rules and that they can be changed Kohlberg identified six stages of moral development under three levels. there is imminent justice b.Study Guide Answer Key 23 16. Level II: Conventional Level: Sees moral reasoning based on his or her own personal internalization of societal and others’ expectations Stage 3: Good boy-nice girl orientation (good motives. 2005 by Mosby. an affiliate of Elsevier Inc. Level III: Post-conventional Level: Balance between human rights and obligations and societal rules and regulations Stage 5: Social contract orientation (follows the societal law but recognizes the possibility of changing the law to improve society) Stage 6: Universal ethical principle orientation (right by the decision of conscience in accord with self-chosen ethical principles) Mosby items and derived items © 2009. Heteronomous morality: occurs between 4-7 years and is characterized by a belief that rules are unchangeable and that when a rule is broken. Inc. Stage 1: Punishment and obedience orientation (in terms of absolute obedience to authority and rules) Stage 2: Instrumental relativist orientation (more then one right view) 18. and keeping mutual relationships) Stage 4: Society-maintaining orientation (expand their focus from a relationship with others to societal concerns) 19. Briefly explain each.. showing concern for others. .

21. 5. Inc. falls. Injury Prevention: MVA. 19. Describe the cognitive changes that occur in the infant: learns by experiencing and manipulating the environment. Summarize the physical changes that occur in the infant: size increases rapidly during the first year of life. reflexes. and sexual abuse 23.Study Guide Answer Key 24 Chapter 12: Conception Through Adolescence 1. and sensory functions 13. but they learn where the self ends and the external world begins b. Separation and individuation: infants are unaware of the boundaries of self. Hyperbilirubinemia: Excessive amount of bilirubin in the blood 14.. 3. Circumcision: benefits include prevention of penile cancer and urinary tract infectiosn (UTIs) 16. birth weight doubles (5 months) and triples (12 months). Identify the language development in the infant and how to help parents further develop the infant’s language: by 1 year. Play: much of the play is exploratory as they use their senses to observe and examine their own bodies and objects of interest in their surroundings 22. an affiliate of Elsevier Inc. Teratogens: Factors that are capable of producing functional or structural damage to the fetus 8. Nagele’s rule: Computes the length of preegnancy Fertilization: Sperm penetrates the ovum Germinal period: First 2 weeks after conception Zygote: newly formed organism with its full genetic complement Embryonic period: The beginning of the third week through the eighth week after conception 6. 2005 by Mosby. Prematurity: infant between 20 to 37 weeks gestation 9. The nurse can promote language development by encouraging parents to name objects on which the infant is focusing. Explain the following psychosocial changes that occur a. Cognitive development: Innate behavior. Briefly explain health concerns related to the following Mosby items and derived items © 2009. Height increases an average of 1 inch every 6 months until 12 months. Molding: Overlapping of the soft skull bones 11. the period from 1 month to 1 year of age 18. Fontanels: diamonds and triangular shapes between the unfused bones of the skull 12. Safety concerns: Car seats and cribs The Infant 17. aspiration. Explain the following in relation to health risks of the infant a. Child maltreatment: intentional physical abuse or neglect. ends with birth 7. or poisoning are major causes of death b. Fetal period: ninth week after conception. . Neonatal period: first month of life 10. emotional abuse or neglect. 2. they not only recognize their own names but are able to say three to five words and understand 100 words. Inborn errors of metabolism: Genetic disorders caused by the absence of deficiency of a substance essential to cellular metabolism 15. sensorimotor period 20. 4.

35. Sleep: infants are nocturnal and sleep between 9 and 11 hours. cause-and-effect relationships. and asks questions for information 31. Immunization: recommended that the administration of the primary series begin after birth and be completed during early childhood c. Vision: regular intervals of screening The School-Age Child 33. Language: increases rapidly. Sleep: average 12 hours a night. . Peers – become more important.Study Guide Answer Key a. Identify the health risks of a toddler: locomotion abilities and curiosity. Describe the moral development of a toddler: they do not understand the concepts of right and wrong. 2005 by Mosby. Describe the concept of play for the preschooler engage in similar if not identical activity. Explain health concerns related to the following for this group a. drowning. the world remains closely linked to concrete experiences. infrequent naps c. poisoning occurs frequently. an affiliate of Elsevier Inc. play involves peers and the pursuit of group goals c. they do grasp pleasant and unpleasant results 27. their greatest fear is bodily harm 30. the use of whole cow’s milk is not recommended before 12 months b. Describe the cognitive changes that occur with the preschooler demonstrate their ability to think in a more complex manner by classifying objects. increased social interaction. The preschool period ranges from years between 3 and 5 29. 26.. Describe language ability at this stage: 10 words to 300 words and is able to speak in two-word sentences. Nutrition: the quality of food is more important than the quantity b. is more social. there is no division of labor or rigid organization or rules 32. Toddlerhood ranges from 12-36 months 25. averaging 15 hours a day The Toddler 24. Sexual – latency period Mosby items and derived items © 2009. 25 Nutrition: feeding alternatives: breast feeding is recommended. MVA The preschooler 28. Inc. The school-age year range from 6 years until 12 years (puberty) 34. Moral development: begins to understand behaviors that are considered socially right or wrong b. Explain the following a. Summarize psychosocial development in relation to the following a. Define the cognitive skills that develop in the school-age child: Define the cognitive skills that develop in the school-age child the ability to think in a logical manner about the here and now and to understand the relationship between things and ideas. They have the ability to concentrate on more than one aspect of a situation and are able to reason about the relationships between classes. Moral – need for moral code and social rules becomes more evident b.

evaluate their own health according to feelings of well-being. Look for meaning behind the words or actions. ability to function normally.. Regarding rules. Development of the reproductive system 40. . Ask open-ended questions. homicide c. Do not avoid discussing sensitive issues. Inc. a. a. suicide 45. ability to determine possibilities. f. accidents b. discuss with parents the learning needs of their child. decrease in school performance b. need to select action that promotes self-satisfaction. mechanics of dental hygiene. physical evidence of maturity encourages the development of behaviors b. similarity in dress or speech and popularity are major concerns c. prevention programs e. 13-20 years 39. 2005 by Mosby. Involve other individuals and resources. food guide pyramid b. Increased growth rate of skeleton. immunization information and prevention practices d. They can move beyond the physical or concrete properties of a situation and use reasoning powers to understand the abstract. biannual check-ups c. a. depends heavily on cognitive and communication skills and peer interaction. substance abuse and poisoning. a. stranger safety 37. burns. Be alert to clues to their emotional state. bodily damage.appropriate education 38. loss of initiative Mosby items and derived items © 2009. and continued opportunity for growth e. Alteration in distribution of muscle and fat d. Identify the health risks for the school-age child: MVA. 26 Stress – from parental expectations. an affiliate of Elsevier Inc. peer expectations. provide age. movement toward stronger peer relationships is contrasted with adolescents' movement from parents d. provides a goal. they learn to use their own judgment rather than use the rules to avoid punishment as in earlier years. 42.Study Guide Answer Key d. the onset of menstruation 41. and absence of symptoms 44. drowning. violence in the community 36. They can think abstractly and deal effectively with hypothetical problems. a. rank and solve problems. puberty enhances sexual identity. muscle and viscera b. withdrawal c. identity. and make decisions through logical operations. school environment. Sex-specific changes c. 43.

education about STDs. they feel a sense of worth. unintentional injuries. Mosby items and derived items © 2009. death related to violence. 4. binge eating and behaviors to prevent weight gain (vomiting. f. If they are positively recognized for success. lack of transportation to health care. learning or emotional difficulties. morality comes from individual principles of conscience. e. continue to offer a variety of nutritious foods 51. encourage abstinence d. an affiliate of Elsevier Inc. exercise) 47. poverty. toddlers often develop food jags or the desire to eat one food repeatedly. 46. a. Inc. thus learning self control 52. but they do understand positive and negative reinforcement. screen for use and inform of the risks for use c. loneliness. poverty. teach conflict resolution 48. The school and home influence growth and development. driver’s education and wear seat belts b. do not understand what is right or wrong. increased rate of adolescent pregnancy. 1.Study Guide Answer Key d. limited health care insurance. limited access to health care. 1. . They establish close relationships and make choices about their vocation. 53. and limited access 50. 2005 by Mosby. sadness. and farming accidents 49. a. laxatives.. 4. and crying appetite and sleep disturbances verbalization of suicidal thought 27 physical and psychosocial components that involve the pursuit of thinness through starvation b.

the period between the late teens and the mid to late 30s 2. and access to guns 10. cohabitation without marriage. habits. availability of contraception. infertility. conception. irregular. identification of modifiable factors that increase the risk for health problems and provide education and support b. parenting disorders. short contractions 20. an affiliate of Elsevier Inc. hobbies and interests. 2005 by Mosby. home conditions and pets. a prolonged time to conceive. the person refines self-perception and ability for intimacy b. important to prevent or decrease the development of chronic health conditions that develop later in life 16.. due to poverty. poor dental hygiene 9. the presence of certain chronic illnesses in the family increases the patient’s risk of developing a disease. physical and mental strain 3. exposure to work-related hazards or agents. remain single. many do not marry until late 20s or early 30s. Inc. the two-career family has benefits and liabilities with resulting stressors c. pregnant woman and childbearing 18. birth. job stress (situational). major health problem and leads to chronic disorders. general health status and age c. a. breast. or death 13. intoxicated MVAs. expanding careers for women. is the period of approximately 6 weeks after delivery Mosby items and derived items © 2009. which can cause disease and cancer 14. economic considerations. comprehensive histories of both the female and male partners to determine factors that affect fertility as well as pertinent physical findings 15. and the puerperium are the major phases 6. exploration of situational factors that affect the progress and outcome (financial. psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse d. career. stimulants. and coping mechanisms) 12. depression. and divorce b. need to perform monthly skin. formal and informal educational experiences. gay and lesbian 7. a. and occupational opportunities increase conceptual problem-solving and motor skills 4. family breakdown. repeated exposure to violence. . general life satisfaction. family stress (multiplicity of changing relationships and structures). the person directs enormous energy toward achievement and mastery of the world c. sharing utensils. pregnancy. family support systems. excessive caffeine use 11. living accommodations. or male self examinations 17. time of vigorous examination of life goals and relationships 5. general life experiences. occupational environment. child abuse and neglect. economics. a. prenatal care is the routine thorough physical examination of the pregnant woman 19.Study Guide Answer Key Chapter 13: Young to Middle Adult 28 1. distinct frrm hereditary disease 8.

which may have a impact on selfconcept and body image 24. menopausal symptoms. and the choice of remarrying or remaining single 30. decreasing availability of jobs. middle adults having the responsibility of raising their own children while caring for aging parents 26. and environment by minimizing the frequency of stress-producing situations. lifestyle. disappointments or losses at work. evaluate health behaviors and lifestyle. Inc. and perceived control of environment.Study Guide Answer Key 29 21. inability of the neurohormonal system to maintain its periodic stimulation of the endocrine system Mosby items and derived items © 2009. related to change. c. which may motivate the adult to rethink life goals and stimulates creativity or precipitates psychosomatic illness and preoccupation with death b. couples recultivate their relationships. conflict. increasing stress resistance. risk factors: female. counseling related to physical activity and nutrition 33. repeated exposure to violence. breast feeding 22. leading to a readjustment phase 31. resulting in a diminished number of ova and irregular menstrual cycles b. an affiliate of Elsevier Inc. and access to guns 35. stresses due to sexual changes or conflicts 28. factors that predispose include poverty. separation. goals of wellness and guides clients to evaluate health behaviors. choice and freedom. departure of the last child. occurs in men in their late 40s or early 50s due to decreased levels of androgens 25. divorce. family breakdown. a. 3. is the disruption of this cycle. need for challenge) 27. thickening of the waist. 2005 by Mosby. changes occur by choice or as a result of changes in the workplace or society (limited upward mobility. and thickening of the waist 36. a. . the most visible changes are the graying of hair. wrinkling of the skin. 1. primarily because of the inability if the neurohormonal system to maintain its periodic stimulation of the endocrine system.. 1. is the period during which ovulation declines. early to mid 30s and last through the late 60s 23. school or relationships. child abuse and neglect. death of a spouse. and decreases in hearing and visual acuity. and avoiding physiological response to stress 32. and family history 34. departure of the last child is a stressor. most visible changes are graying of the hair. wrinkling of the skin. adoption 29. delayed marriage and delayed parenthood.

a. self-focused activities b. home (should not feel like a hospital) b. family involvement (should encourage involvement) d. 7. the effects of disease and disability on functional status 14. 5. environment (ample lighting. plants. redefining relationships with adult children g. age 65 and over d c a b ill. dehydration d. 6. disabled. and physically unattractive forgetful. a. a. Inc. 3. a. confused.. 2005 by Mosby. 2. rigid. staff (attentive to resident requests) 12. the interrelation between physical and psychosocial aspects of aging 13. pets) e. finding ways to maintain quality of life 11. change in mental status b. communication (respectful and considerate) f. adjusting to the death of a spouse d. adjusting to retirement and reduced or fixed outcome c. 9. an affiliate of Elsevier Inc. care (staff actively assisting and interacting socially) c. 8. altered presentation and response to specific disease 17. falls c. that personality remains the same and behavior becomes more predictable as people age 10. bored and unfriendly mistaken ideas about living arrangements undervaluing due to unattractiveness as the result of random cellular damage that occurs over time genetically programmed physiological mechanisms within the body control the process of aging 30 the oldest. the lack of standards for health and illness norms 16. states that aging individuals withdraw from customary roles and engage in more introspective. continuation of activities performed during middle age as necessary for aging c. minimal noise. . maintaining satisfactory living arrangements f. accepting self as aging person e. b. 4. decrease in appetite Mosby items and derived items © 2009. adjusting to decreasing health and physical strength b. c. d.Study Guide Answer Key Chapter 14: Older Adult 1. the decreased efficiency of homeostatic mechanisms 15. a.

regular exercise c. accidents/falls f. a.Study Guide Answer Key 31 e. i 23. b 22. h 25. well-balanced diet e. sufficient income) b. Inc. stage of life characterized by transitions and role changes (health status. 2005 by Mosby. d. e 26. d 19. option to continue working. regular dental visits f. . heart disease b. f 20. whether healthy or frail there is a need to express sexual feelings (love. potentially reversible. 29. g 21. weight reduction. Functional status refers to the capacity and safe performance of activities of daily living (ADLs) and is a sensitive indicator of health and illness. by choice (desire not to interact with others) or a response to conditions that inhibit the ability or the opportunity to interact with others c. a. lung disease e. a. often due to a physiological cause b. death of a spouse affects more older women then men 31. smoking cessation Mosby items and derived items © 2009. sharing and touching) d. kidney disease h. an affiliate of Elsevier Inc. CVA d. a. dizziness and incontinence 18. generalized impairment of intellectual functioning that interferes with social and occupational functioning c. health status) e. acute confusional state. not a normal part of aging 30. a 27. j 24. diabetes g.. family responsibilities. participation in screening activities b. the ability to live independently strongly determines housing choices (social roles. loss of function f. eating a low fat. c 28. warmth. cancer c. liver disease 32.

Often due to the result of retinal damage. Mosby items and derived items © 2009. 2005 by Mosby. and constipation 53. c 47. f 43. cluttered environment) 55. medications. g 37. a. or cognitive impairment) or extrinsic (polypharmacy. a 52. m 41. immunizations 33. Inc. Beyond caloric requirements. excessive urine production. causes include delirium. reduced pupil size. 57. 58. It is the stage of life characterized by transitions and role changes. k 38. l 40. 1. f 51. related to changes in aging and to immobility.. d 45. sodium. 4. and malnutrition 54. restricted mobility. h 35. or simple sugars or increase fiber or foods high in calcium. 3. c 34. b 50. 4. a 42. depression. iron. continues the recovery from acute illness or surgery that began in the acute care setting b. intrinsic (gait and balance problems. It potentially is a reversible cognitive impairment that is often due to physiological causes. incontinence. and vitamins A or C. b 44. . therapeutic diets restrict fat. e 48. poor lighting. e 36. d 49. untreated UTIs. j 46. an affiliate of Elsevier Inc.Study Guide Answer Key 32 g. addresses chronic conditions that affect day-to-day functioning 56. development of opacities in the lens or loss of lens elasticity 59. weakness. i 39.

seek the true meaning of a situation b. j 16.. an affiliate of Elsevier Inc. Is an active. g 15. b 22. accountability 5. be eager to acquire new knowledge and value learning g. i 23.Study Guide Answer Key Chapter 15: Critical Thinking in Nursing Practice 1. knowledge base b. k 24. a. c 6. 2. c 14. anticipate the need to make choices without assistance from others. Inc. f 21. organized. experience c. a 8. h 19. . b 10. be organized e. e 12. e 18. a. a. begin to separate themselves from authorities. 2005 by Mosby. a 17. reflect upon your own judgments 4. attitudes e. a. trust that experts have the right answers for every problem. trust in your own reasoning processes f. cognitive process used to examine one’s thinking and the thinking of others. thinking is concrete and based on a set of rules or principles b. d 7. d 20. based on research or clinical expertise 3. be tolerant of different views and own prejudices c. anticipate possible results or consequences d. f 11. critical-thinking competencies d. standards 13. g 9. is a guideline or principle for rational thought 33 Mosby items and derived items © 2009. analyze and examine choices more independently c.

4. an affiliate of Elsevier Inc. interventions. diagnosis. involves recognizing an issue exists. is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning 26. is a visual representation of client problems and interventions that shows their relationships to one another 27. Inc. evaluating information. the 5 steps are assessment.. refers to ethical criteria for nursing judgments. identifying a client’s health care needs 30. implementation 34 Mosby items and derived items © 2009. evaluation 29.Study Guide Answer Key b. 4. evidence-based used for evaluation and criteria for professional responsibility 25. 3. analyzing information. and making conclusions 28. . 2005 by Mosby. 4. plan.

coping-stress tolerance pattern 16. data about the client’s current level of wellness. present. Inc. c 5.Study Guide Answer Key Chapter 16: Nursing Assessment 35 1. sleep-rest pattern 11. objective – observations or measurements of a client’s health status 18. establish a caring therapeutic relationship c. self-perception-self-concept pattern 13. or future physical or mental health or condition b. value-belief pattern 17. family and significant others c. . a 6. the past. client b. medical records e. determine the client’s goals and expectations e. health care team d. open ended: prompts clients to describe a situation in more than one or two words b. back-channeling: active listening prompts c. the provision of health care to the individual c. a. present. an individual’s past. and mental and emotional reactions to illness 22. obtain cues about which parts of the data collection phase require further investigation 20. literature 19. introduce yourself. d 2. subjective – clients’ verbal descriptions of their health problems b. or future payment for provision of health care to the individual 21. review of systems. a.. a. nutritional-metabolic pattern 8. health perception-health management pattern 7. cognitive-perceptual pattern 12. b 4. get insight about the client’s concerns d. spiritual history. sexuality-reproductive pattern 15. family history. explain your role b. a. elimination pattern 9. a. role-relationship pattern 14. e 3. activity-exercise pattern 10. 2005 by Mosby. closed-ended: limit the client’s answers to one or two words Mosby items and derived items © 2009. an affiliate of Elsevier Inc. sociocultural history.

2. d 33. 1. . b 31. an affiliate of Elsevier Inc. involves recognizing patterns or trends in the clustered data. j 30. pay attention to facts and be descriptive. Prompts clients to describe a situation in more than one or two words 37. record objective information in accurate terminology. 3. a 32. timely. do not generalize or form judgments 36. comparing them with standards. and then coming to a conclusion about the client’s responses to a health problem 35. asking questions about the normal functioning of each system and the changes are usually subjective data perceived by the client 36 Mosby items and derived items © 2009. i 28. Takes information provided in the client’s story and then more fully describes and identifies specific problem areas 39. h 27. 38. record all observations. Some may be focused. thorough.Study Guide Answer Key 23. 2005 by Mosby. g 25.. and accurate. 4. Inc. c 29. e 26. is the comparison of data with another source to determine data accuracy 34. f 24. and others may be comprehensive.

it describes the essence of the client’s response to health conditions 9. 37 d e f b c g a is the name of the diagnosis as approved by NANDA. 4. Review your level of comfort and competence with interview and physical assessment skills. genetic. 15. physiological.Study Guide Answer Key Chapter 17: Nursing Diagnosis 1. 2. 21. be careful to consider any conflicting cues or if there is insufficient cues to confirm a diagnosis. 6. 20. 5. Provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is responsible. concise. Avoid premature clustering of data. use correct terminology. not the reverse. is the one way to graphically represent the connections between concepts and ideas that are related to a central subject 14. 2. 16. 22. an affiliate of Elsevier Inc. is the diagnostic label that describes the essence of a client’s response to health conditions 24. It is associated with the client’s actual or potential response to the health problem.. Be organized in any examination. 18. 3. 23. 25. 4. 2005 by Mosby. 17. avoid legally inadvisable statements. the client’s actual or potential response to the health problem Mosby items and derived items © 2009. identify the client problem rather than the goal. Review your clinical assessment skills. Word the diagnostic statement in appropriate. and precise language. 4. always identify the nursing diagnosis from the data. 19. psychological. 7. . describes the characteristics of the human response identified 12. make professional rather than prejudicial judgments. Inc. Approach assessment in steps. are environmental. 4. or chemical 13. 8. actual or potential responses to the health problem 10. the cause of the nursing diagnosis within the domain of nursing practice 11. Determine the accuracy of your data. Review your data base to decide if it is accurate and complete. is a condition or etiology identified from the client’s assessment data.

non-threatening needs of the client are not always directly related to a specific illness or prognosis 38 d b e c f a outcomes and goals reflect the client’s behavior and responses expected as a result of nursing interventions 9. precise in evaluating a client response to a nursing action. are part of the client’s legal record and differ by setting and the evolving client situation 22. 8. multidisciplinary treatment plans that outline treatments or interventions clients need to have. physician-initiated interventions that require an order for a physician or other health care professional 17. identifies and coordinates resources for delivering care. nursing process. indicates when you expect the response to occur 13. quantity. or weight allow you to evaluate outcomes precisely 12. nurse-initiated interventions that do not require direction or an order from another health care professional 16. result in harm to the client or others involve nonemergent. 6. lists the interventions needed to achieve the goals of care 20. feasibility of the interventions e. that a client is able to reach 15. 7. Inc. b. 4. 5. terms describing quality. interdependent nursing interventions that require the combined knowledge.. frequency. a. which the nurses are able to individualize for a specific client 23. most are based on medical diagnoses rather then nursing Mosby items and derived items © 2009. or inaccurate care. be able to observe if a change takes place in a client’s status 11. 2005 by Mosby. characteristics of the nursing diagnosis b. direct clinical nursing care and to decrease the risk of incomplete. . your own competency 19. goals and expected outcomes c. evidence-based interventions d. skills of written communication. if untreated. 3. 2. length. addresses only one behavior or response per goal 10. useful for learning the problem-solving technique. c.Study Guide Answer Key Chapter 18: Planning Nursing Care 1. ensure that the client and nurse agree on the direction and time limits of care 14. acceptability to the client f. and expertise of multiple care professionals 18. skill. and organizational skills needed for nursing care 21. a. an affiliate of Elsevier Inc. incorrect. format is standardized plans.

provide the consultant with relevant information about the problem area d. Revise. Use the map to write down the responses to each nursing activity. take notes. When planning. and add or delete nursing interventions. 30. is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies 34. Gather the clinical assessment data base from the client’s medical record. an affiliate of Elsevier Inc. be available to discuss the findings and recommendations f. usually less than a week 36. Identify and group the related patterns. 29. treatments. . 2005 by Mosby. a. Inc.Study Guide Answer Key 39 24. 25. Review any standardized care plans. 32. and medication in the literature. 26. 33. analyze relationships among the nursing diagnoses. List the nursing interventions to attain the outcomes for each nursing diagnosis. do not prejudice or influence the consultants e. or client education material. 3. identify the general problem area b. incorporate the recommendations into the plan of care 35. Mosby items and derived items © 2009. protocols. 2. 28. critical pathways. 27. is the measurable change in a client’s condition that you expect to occur in response to the nursing care 37. is an objective behavior or response that you expect a client to achieve in a short time. 31. 4. develop a skeleton diagram of the client’s chief medical diagnosis and patterns of assessment data. direct the consultation to the right professional c. Review your assessment patterns and identify nursing diagnoses.. Review all of the information about the client’s problems. The nurse sets client-centered goals and expected outcomes and plans nursing interventions. First.

4. writing checks. and the environment 9. 8. 2005 by Mosby. Risks to patients come from both the illness and the treatments. you collect new data. or protocol is a document that guides decisions and interventions for specific health care problems or conditions. is a preprinted document containing orders for the conduct of routine therapies. skilled personnel. are treatments performed away from the client but on behalf of the client 2. 10. activities usually performed in the course of a normal day (ambulation. promote health and prevent illness to avoid the need for acute or rehabilitative health care 18. identify a new client need. . preparing meals. and/or diagnostic procedures for clients with identified clinical problems 5. modify the nursing care plan. is a harmful or unintended effect of a medication. a. determine the probability of all possible consequences d. or therapeutic intervention 17. a. interpersonal (trusting relationship. diagnostic test. the focus of change is intellectual growth or the acquisition of new knowledge or psychomotor skills 16. grooming) 12. is a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships 15. bathing. represents the contributions of all disciplines caring for the client 19. organization of equipment. that a nurse performs to enhance client outcomes b. monitoring guidelines.. Mosby items and derived items © 2009. dressing. based upon clinical judgment and knowledge. includes cognitive (application of critical thinking in the nursing process). continuous process that occurs each time you interact with a client. 40 is any treatment. offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes 6. eating. are treatments performed through interactions with clients c. an affiliate of Elsevier Inc. If the client’s status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate.Study Guide Answer Key Chapter 19: Implementing Nursing Care 1. Inc. The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care. make a judgment of the value of that consequence to the client 3. noninvasive and frequently repetitive interventions can be assigned to assistive personnel (nurse assistant). and modify the care plan 7. review all of the possible consequences associated with each possible nursing action c. involve the safe and competent administration of nursing procedures 14. review the set of all possible interventions for the client’s problem b. level of caring and communication) and psychomotor skills (integration of cognitive and motor activities) 11. taking medications 13. skills such as shopping.

certain nursing situations require you to obtain assistance by seeking additional personnel.. the nurse needs to exercise good judgment and decision-making before actually delivering any interventions 22.Study Guide Answer Key 41 20. 1. 2. an affiliate of Elsevier Inc. 1. 4. You will need assistance with this patient to help turn and position the client safely. an acquisition of new knowledge or psychomotor skills Mosby items and derived items © 2009. guides decisions and interventions for specific health care problems or conditions 24. Inc. 23. that clients and families invest time in carrying out required treatments to achieve client goals 21. . 2005 by Mosby. and/or nursing skills. knowledge.

They are the standards against which the nurse judges if goals have been met and if care is successful. documenting findings and any clinical judgment e. a. managing the individual clinical outcomes of clients as a result of prescribed treatments 11. Inc. an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others 10. Mosby items and derived items © 2009. what are the barriers? 4. then discontinue that portion of the care plan. and time-appropriate 8. this is an ongoing process 13. 2. or revising the care plan 3. Determines whether the client’s condition or well-being has improved after the application of the nursing process 12. terminating.Study Guide Answer Key Chapter 20: Evaluation 42 1. If the goals have not been met. assess the client’s actual behavior or response c. 2005 by Mosby. They are the expected favorable and measurable results of nursing care. If the nurse and the patient agree that the expected outcomes and goals have been met. 6. Identify the factors that interfere with goal achievement or an error in nursing judgment or failure to follow each step of the nursing process. not if the nursing interventions were completed. you may need to adjust the plan of care by the use of interventions. Determine if your goals have been met. the appropriateness of the interventions selected and the correct application of the intervention 9. if there is no agreement between the outcome criteria and the actual behavior. and redefine priorities. collecting data to determine whether the criteria or standards are met c. Determine if the goals were appropriate. Whenever you have contact with a client. interpreting and summarizing findings d. realistic. 3. 2. 7. 2. a. to determine if you met the expected outcomes. continuing. judge the degree of agreement between outcome criteria and the actual behavior e. identifying evaluative criteria and standards b. you continually make clinical decisions and redirect nursing care. 2.. and then adjust the plan of care accordingly. 14. modify or add nursing diagnoses with appropriate goals and expected outcomes. an affiliate of Elsevier Inc. compare the established outcome criteria with the actual behavior d. . 5. examine the outcome criteria to identify the exact desired client behavior b.

time analysis. a. staff communication 15. and keep one another informed. g 11. communicate clearly d. f 8. As a student nurse. A professional environment is one in which staff members respect one another’s ideas. i 10. evaluation 21. is an ongoing process that compares actual client outcomes with expected outcomes 22. priority setting. you have a responsibility for the care given to your clients. 17. and you assume accountability for that care. staff education 16. provide feedback 25. an affiliate of Elsevier Inc. h 9. intermediate (non-emergent. listen attentively e. low (actual or potential problems) 18. e 3. assess the knowledge and skills of the delegate b. 2005 by Mosby. c 7. interruption control.Study Guide Answer Key Chapter 21: Managing Client Care 43 1. The first activity involves a focused and complete assessment of the client’s condition to allow for an accurate clinical decisions as to the client’s health problems and required nursing therapies. effective use of time doing the right things 19. need to set priorities: high (immediate threat). . goal setting. nurse/physician collaborative practice 13. match tasks to the delegate’s skills c. share information. non-lifethreatening). j 6. right direction/communication e. right circumstances c. a 5. 20. right person d. d 2.. a. right task b. 23. interdisciplinary collaboration 14. establishment of nursing practice or problem-solving committees or professional shared governance councils 12. b 4. right supervision 24. Mosby items and derived items © 2009. Administration of client care occurs more smoothly when staff members work together. Inc. 4.

2. clarify values d. custom. value of something is determined by its usefulness. and opinion 10. 23. focuses on inequalities between people. negotiate a plan g. You are able to resolve it solely through a review of scientific data. Inc. The answer to the problem will have a profound relevance for areas of human concern.Study Guide Answer Key Chapter 22: Ethics and Values 1. an affiliate of Elsevier Inc. need to distinguish between value. 7. or object that sets standards that influence behavior 8. verbalize the problem e. 4. ask the question b. facts. the main emphasis is on the outcome or consequence of actions 12. interventions unlikely to produce benefit for the client 22. . attitude. development of values begins in childhood. 4. 2. shaped by experiences within the family unit with individual experiences influencing further value formation 9. truthfulness. 17. does not look at the consequences of actions 11.. and case consultation 19. 2005 by Mosby. Ethical problems come from controversy and conflict. conditions that are not yet evident but that are certain to develop in the future 21. b. d b e c a 44 responsibility accountability confidentiality advocacy personal belief about the worth of a given idea. education. d. especially personal narratives 14. a. policy recommendation. The ethics committee is an additional resource for clients and health care professionals. It is perplexing. identify possible causes of action f. a system of ethics that defines actions as right or wrong based on their “right-making characteristics such as fidelity to promises. 15. a. 5. c. focuses on understanding relationships. 16. Mosby items and derived items © 2009. evaluate the plan over time 18. gather information relevant to the case c. helps a client and family decide on the merits of certain risky interventions 20. it looks to the nature of relationships for guidance 13. 6. and justice”. 3.

Inc..Study Guide Answer Key 45 24. and family situation. current literature about the condition. cultural. Mosby items and derived items © 2009. and the client’s religious. . an affiliate of Elsevier Inc. Incorporate as much information as possible from a variety of sources such as lab and test results. clinical state of the client. 2005 by Mosby. 4.

only on the written order of a physician. and offers legal immunity for nurses who help at the scene of an accident 20.Study Guide Answer Key Chapter 23: Legal Implications in Nursing Practice 46 e h f b c g d a It protects the rights of disabled people. regulating health care and health care financing. 4. written documents that direct treatment in accordance with a client’s wishes in the event of a terminal illness or condition 14. 2005 by Mosby. 10. The Board of Nursing licenses all RNs in the state in which they practice and can suspend or revoke a license if a nurse’s conduct violates provisions in the licensing statute based on administrative law rules that implement and enforce the statute. It also establishes the basis for privacy and confidentiality. 2. If an emergency exists. Inc. that when a client comes to the ER/hospital. limits liability. law that encourages health care professionals to assist in emergencies. 1. a. 3. needs to make the gift in writing with his or her signature. which includes a specific episode with start and end times 18. only to ensure the physical safety of the resident or other residents b. Mosby items and derived items © 2009. an appropriate medical screening occurs within the hospital’s capacity. 5. Determination of death requires irreversible cessation of circulatory and respiratory functions or that there is irreversible cessation of all functions of the entire brain. . the hospital is not to discharge or transfer the client until the condition stabilizes. and ensuring professional accountability for the care provided 21. 7. legal document that designates a person or persons of one’s choosing to make health care decisions when the client is no longer able to make decisions on his or her own behalf 15. 9. an affiliate of Elsevier Inc. provides rights to clients (protects individuals from losing their health insurance when changing jobs by providing portability) and protects employees. 8. requires health care institutions to provide written information to clients concerning their rights under state law to make decisions. 17. An individual over the age of 18 has the right to make an organ donation. It also is the most extensive law on how employers must treat health care workers and clients infected with HIV. forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits 12.. protection of the public’s health. 19. 11. including the brain stem. including the right to refuse treatment and formulate advance directives 13. 16. when less restrictive interventions are not successful c. 6. advocating for the rights of people.

need to inform the supervisor of any lack of experience in caring for the type of clients on said unit. c 29.Study Guide Answer Key 47 22. If there is any controversy with the order. provides a database for further investigation in an attempt to determine deviations from standards of care.. an affiliate of Elsevier Inc. 4. 4. Keep a copy of this document in your own personal file. Nurses must follow the physician’s orders unless they believe the orders are in error or will harm the clients. 35. 2005 by Mosby. h 27. unintentional touching without consent 42. they need to make a written protest to nursing administrators. d 24. g 25. 3. need to follow the institution’s policies and procedures on how to handle these situations and utilize the chain of command Mosby items and derived items © 2009. a 33. corrective measures needed to prevent recurrence and to alert risk management to a potential claim situation 38. f 30. i 28. b 32. . 34. Inform their supervisor. 1. conduct that falls below the standards of care 41. 23. e 26. system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs 37. 1. Determines the legal boundaries within each state 39. They also need to request an orientation to the unit. Inc. 36. Need to perform only those tasks that appear in the job description for a nurse’s aide or assistant 40. the nurse needs to also inform the supervising nurse or follow the established chain of command. Statute that stated that a competent individual with a terminal disease could make an oral and written request for medication to end his or her life in a humane and dignified manner. j 31.

e 7.– 4 ft) c. when the nurse and client meet and get to know one another (set the tone for the relationship.. c 10. through the 5 senses b. d 22. plan enough time for interaction) 25. a. h 16. a 15. relinquishing responsibility. self-exploration. transition to other caregivers as needed) Mosby items and derived items © 2009. an affiliate of Elsevier Inc. b 6. intimate zone (great sensitivity needed) d. j 12. g 9. and confrontation used appropriately) 27. k 19. public zone (12 ft and greater) 23. anticipate health concerns. b 17. talk to caregivers. social zone (9 – 12 ft) d. clarify the roles of the client and the nurse) 26. n 20. before meeting the client (review data. vulnerable zone 24. intimate zone (0 –18 inches) b. is a lifelong learning process that is an essential attribute of professional nursing practice 2. a.Study Guide Answer Key Chapter 24: Communication 48 1. expect to be tested and closely observed. f 11. d 5. set goals. e 21. consent zone (special care needed) c. when the nurse and the client work together to solve problems and accomplish goals (help the client to express feelings. individual’s culture and education 3. i 18. selfdisclosure. 2005 by Mosby. a 8. c 4. take action. . m 14. during the ending of the relationship (termination is near. l 13. goal achievement. social zone (permission not needed) b. personal zone (18 in. a. Inc.

a. p 45. psychophysiological (the internal factors influencing communication) b. courtesy b. or absent ability to receive. a 44. 2005 by Mosby. client initiates conversation about the diagnosis b. delegation. n 46. autonomy and responsibility e. and relationships 29. . f 43. collaboration. and difficulty in comprehending 36. client will express increased satisfaction with the process 38. inability to articulate words. k 48. difficulty forming words. a. tend to use less verbal communication but are more likely to initiate communication and address issues more directly b. psychological. a. facilitating group processes. delayed. newspapers. radio. cultural (sociocultural elements that affect the interaction) 33. disclose more personal information and use more active listening 34. leadership. or developmental 37. supervision. transmit. m 41.. and management 30. assertiveness 32. relational (the nature of the relationship between the participants) c. client conveys clear and understandable messages with team d. through channels such as neighborhood newsletters. j Mosby items and derived items © 2009. trustworthiness d. a. environmental (physical surroundings in which the communication takes place) e. consultation. o 42. inappropriate verbalization. includes the understanding of the complexities of family dynamics. needs. client is able to attend to appropriate stimuli c. b 49. TV. public bulletin boards. e 39. g 40. and electronic sites to discuss issues important to community health 31.Study Guide Answer Key 49 28. Inc. an affiliate of Elsevier Inc. cultural. anatomical. use of names c. and use symbols) 35. focuses on team-building. situational (the reason for the communication) d. impaired verbal communication (state in which the individual experiences a decreased. mechanical. physiological. process. l 47.

68. k 56. 1. 78. Examine the type and number of questions asked. Determine whether nursing responses were positive and supportive or superficial and judgmental. use14-font print. f 58. 72. Listen attentively. Identify any missed verbal or nonverbal cues or conversational themes. do not shout. d 53. do not rely on gestures or nonverbal communication. meaning of a word’s meaning influenced by the thoughts. Speak to client in normal tone. 2005 by Mosby. Check for hearing aids. c 60. j 57. get client’s attention. b 65. personal zone when taking a client’s history Mosby items and derived items © 2009. Call client by name. develop communication aids. 73. and tactile senses 79. h 54. use visual cues. 76. use indirect lighting. speak to client as though he can hear. avoid using family. ask one question at a time. auditory. means of conveying and receiving messages through visual. 3. 75. 66. Determine the type and number of therapeutic communication techniques used. i 64.Study Guide Answer Key 50 50. Discover any missed opportunities to use humor. verbally and by touch. reduce noise. d 62. use simple sentences. do not interrupt. allow time. get client’s attention prior to speaking. 74. Check for glasses.. Determine whether he encourages openness and allow the client to “tell his story” expressing both thoughts and feelings. rephrase. e 61. motivates one person to communicate with the other 82. g 55. 3. ask simple questions. feelings. establish method to signal desire to communicate. awareness of the tone of verbal response and the nonverbal behavior results in further exploration 80. silence. or touch. Inc. 4. 4. or ideas people have about the word 81. . explain all procedures. 67. speak in a normal voice. c 52. Reduce distractions. speak in normal tone. provide an interpreter. an affiliate of Elsevier Inc. provide sign language. allow time. 70. Examine whether nursing responses blocked or facilitated the client’s efforts to communicate. don’t chew gum. a 63. 77. 69. face client. h 59. use communication aids. 71. identify yourself. i 51. provide orientation.

The nurse learns to identify client’s willingness to learn and motivate interest in learning 3. 16. requires assessment of all sources to date to determine a client’s total health care needs b. intellectual growth moves from the concrete to the abstract as the child matures. Adults tend to be self-directed learners. behavior b. and sensory acuity. the following physical characteristics are necessary: size. an affiliate of Elsevier Inc. a 11. 4. g 9. The nurse is a visible. bargaining d. Information presented to children needs to be understandable and based on the child’s developmental stage. Inc. i 8. coordination. The amount of information provided and the amount of time varies depending on the client’s personal situation and readiness to learn. b 13. e 10. resolution e. h 6. denial or disbelief b. d 12. a. 2. 2005 by Mosby. focuses on the client’s learning needs and willingness and capability to learn 18. client’s experiences that influence the need to learn c. information that the family members require 19. a. f 7. a. competent resource (information and skills) for clients who want to improve their physical and psychological well-being. health beliefs and sociocultural background c. 15. acceptance 14. New knowledge and skills are often necessary for clients to continue ADLs and learn to cope with permanent health alterations. 17. . they often become dependent in new learning situations. information or skills needed by the client to perform self-care and to understand the implications of a health problem b. To learn psychomotor skills. anger c. perceived ability to perform behaviors Mosby items and derived items © 2009. strength.Study Guide Answer Key Chapter 25: Client Education 51 1. perception of severity and susceptibility of a health problem and the benefits and barriers to treatment d. a. depends on the child’s maturation. c 5..

b. d. and alert. 27. receptive. movement. Documentation of client teaching supports quality improvement efforts and promotes third-party reimbursement. the inability to read above a fifth-grade level 24. 22. i 31. nursing diagnoses. Inc. f. c 29. dexterity. and organize the activities to provide time for rest and teaching learning interactions. Organize information into a logical sequence progressing from simple to complex ideas. 21. 26. b. willingness and ability to participate in care d. financial or material resources e. desire to learn attitudes about providers learning style preference physical strength. Plan for when a client is most attentive. 28. . h 33.Study Guide Answer Key e. a. an affiliate of Elsevier Inc. e 30. teaching tools 23. 2005 by Mosby. Base the priorities on the client’s immediate needs (perception of what is most important. b 38. 20. a 34. c. g 35. a. j 32. c. legally responsible for providing accurate.. and coordination sensory deficits reading level developmental level cognitive function physical symptoms that interfere distractions or persistent noise comfort of the room room facilities and available equipment 52 willingness to have family members and others involved in the teaching plan family members’ perceptions and understanding of the illness and its implications c. Mosby items and derived items © 2009. d 36. f. f 37. 25. g. and amount of time available). The diagnostic statement describes the specific type of learning need and its cause. timely client information that promotes continuity of care. e. anxiety level. and the goals and outcomes established for the client. classifying the nursing diagnoses by the 3 learning domains helps the nurse focus specifically on subject matter and teaching methods. a. b.

4. 40. Inc. Mosby items and derived items © 2009. an affiliate of Elsevier Inc. takes considerable practice but is developmentally appropriate. 3. 2005 by Mosby. 2. 4. 42.. Teaching complicated skills.Study Guide Answer Key 53 39. 4. whereas a high level of anxiety prevents learning from occurring. 43. involves acquiring skills that integrate mental and muscular activity 41. such as learning to use a syringe. Outcomes describe a behavior that identifies the client’s ability to do something upon completion of teaching with realistic time frames. It is a force that acts on or within a person that causes the person to behave in a particular way. A mild level of anxiety motivates learning. .

j 22. client education on privacy protections b. f 13. d 15. the use of accepted abbreviations. a 16. a. Inc.Study Guide Answer Key Chapter 26: Documentation and Informatics 54 1. 3. co-morbidities. a series of decision trees designed to cluster groups of clients together by diagnosis. complications. receiving client consent before information is released d. or audiotaped exchanges between caregivers 8. c 32. e 28. anything written or printed that you rely on as record or proof for authorized persons 2. immediate documentation of information as it is collected from the client 20. b 29. an affiliate of Elsevier Inc. Joint Commission specifies guidelines for documentation. permanent legal documentation of information relevant to a client’s health care 7. as well as evidence of client and family teaching and discharge planning 6. hears.. e 33. h 26. . f 25. i 24. descriptive. c 11. and system of measures that are clear and easy to understand 18. Communicate information in a logical order 21. timely entries. symbols. d 31. objective information about what a nurse sees. and age 4. containing appropriate and essential information 19. c 23. requires documentation within the context of the nursing process. surgical procedures. e 12. g 27. a Mosby items and derived items © 2009. b 14. an arrangement for services by another care provider 10. providing recourse if privacy protections are violated 5. is a confidential. b 34. oral. written. 2005 by Mosby. form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver 9. a 30. and smells 17. ensuring client’s access to his or her medical records c. feels.

client’s name. 46. need for any additional equipment 49. including the date and time. or scratch out errors made while recording. write TO or VO. 45. document the client’s exact words within quotation marks whenever possible. apply correction fluid. 41. Evaluate results of nursing or medical care measures. who was called. emergency code status f. When recording subjective data. should be most current and accurate continuous source of information about a client’s health care status 50. allergies e. 42. who made it. family support g. physician must co-sign the order within the time frame required by the institution 48. and diagnosis b. name of the client. and what information was received. Continuously review ongoing discharge plan. 47. 38.. f 36. any critical assessments or interventions to be completed i. 39. it may appear as if you were attempting to hide information or deface the record. 3. Identify the client’s nursing diagnosis or health care problems and their related causes. use clarification questions d. repeat any prescribed orders back to the physician c. 40. age. 51. 3. and the complete order. Describe instructions given in teaching plan and the responses to instructions. follow agency policies f. Describe objective measurements or observations about condition and responses to health problem. Share significant information about family members. a. Mosby items and derived items © 2009. Be clear about priorities to which oncoming staff must attend. current nursing diagnoses or problem and care plan h. primary physician. and medical diagnosis b. Provide only essential background information. current health status d. room number. what information was given. Relay to staff any significant changes in the way therapies are to be given. 44. Inc. 43. 2005 by Mosby. clearly determine the client’s name. summary of progress c. d 37. to whom information was given. 4. . Do not erase. An effective report describes each client’s health status and lets staff on the next shift know what care the clients will require. a. 53. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client.Study Guide Answer Key 55 35. and sign the physician name and the nurse e. The nurse includes when the call was made. 52. an affiliate of Elsevier Inc. 2. 4.

d 11. 2005 by Mosby. Is an individual’s conceptualization of himself or herself. or role performance. perceived reactions of others to one’s body c.Study Guide Answer Key Chapter 27: Self-Concept 56 1. actual and potential selfconcept stressors and coping patterns (nature. b 19. personality characteristics g. racial. ability to convey a nonjudgmental attitude toward clients 25. i 4. body image. and role performance. preconceived attitudes toward cultural differences 26. g 8. h 18. and illness 22. The individual’s perception of the stressor is the most important factor in determining his or her response. ongoing perceptions and interpretations of the thoughts and feelings of others d. e 6. academic and employment-related identity f. and spiritual identity 3. an affiliate of Elsevier Inc. a. 13.. including inability to handle situations or events and difficulty making decisions Mosby items and derived items © 2009. if the person expresses a predominantly negative self-appraisal. d 15. f 16. sense of competency b. and perceptions. awareness of how one’s own nonverbal communication affects clients and families 23. number. g 14. 2. h 10. attitudes. c 17. any real or perceived change that threatens identity. e 20. ethnic. body image. thoughts and feelings about lifestyle. f 5. focus on identity. . personal values and expectations and how these affect clients 24. mastery of prior experiences i. b 7. c 12. health. and intensity of stressors and internal and external resources) 27. It is a complex mixture of unconscious and conscious thoughts. a 9. a 21. Inc. perceptions of events h. personal and professional relationships e.

adequate sleep and rest. stress-reducing practices 30. Attitudes toward body image can occur as a result of situational events such as the loss of or change in a body part. 3.5 in the text. 29. Mosby items and derived items © 2009. regular exercise within client’s capabilities.. or function. 34.Study Guide Answer Key 57 28. including physical appearance. structure. Will be able to voice the recognition that losing her job is not reflective of her worth as a person. 4. involves attitudes related to the body. an affiliate of Elsevier Inc. which is affected by cognitive and physical development as well as cultural and societal attitudes 33. . 2005 by Mosby. proper nutrition. Refer to Figure 27. 4. and acceptance of change in appearance or function 31. 35. Will attend a support group for out-of-work professionals. The client will discuss a minimum of 3 areas of her life where she is functioning well. statements of self-acceptance. 32. 2. Certain behaviors become common depending on whether they are approved and reinforced. Inc. Adolescence is a particularly critical time when many variables affect self-concept and self-esteem. nonverbal behaviors indicating positive self-concept.

Study Guide Answer Key Chapter 28: Sexuality 58 1. a.. changes in the appearance or body image c. information. consistently use a water-soluble lubricant before sexual intercourse within 1 week b. functional c. STD prevention 16. discuss stressors that contribute to sexual dysfunction with partner within 2 weeks Mosby items and derived items © 2009. personal and emotional conflicts d. sexual dysfunction 17. relationship d. a. a. a history of or current physical or sexual abuse d. anal intercourse. contaminated IV needles. oral-genital sex. developmental factors f. sexual abuse c. physical b. a. specific. history of surgery of reproductive organs b. chronic illness or developmental milestones (puberty or menopause) 20. b 11. contraception b. self-esteem factors 18. j 8. suggestions. Permission. f 2. e 6. a. . infertility b. therapy 19. h 3. discussing sexual issues 15. g 4. a 13. i 5. intensive. Inc. a. and transfusion of blood products 14. abortion c. c 12. an affiliate of Elsevier Inc. 2005 by Mosby. vaginal intercourse. lifestyle e. d 7. l 10. k 9. limited. impact of pregnancy and menstruation on sexuality b.

Communicate your concerns and fears with partner. and acceptable sexual practices for self and partner within 4 weeks 59 21. Inc. an affiliate of Elsevier Inc. satisfying. kissing.. safe sex practices c. . Mosby items and derived items © 2009. sexual concerns. 27. a. The child identifies with the parent of the same sex and develops a complementary relationship with the parent of the opposite sex. hugging. Pap smears e. and their level of satisfaction b. 23. emotional stress of a prognosis. 34. Eat well-balanced meals. Encourage touch. women (regular breast self-exams. 33. 1.Study Guide Answer Key c. concern about future functioning. 24. Use pillows and alternate positioning to enhance comfort. Plan sexual activity for times when couple feels rested. Refer to Figure 28-2 in your text. 29. mammograms. 4. 30. Individuals experience major physical changes. Avoid alcohol and tobacco. 32. a. ask clients questions about risk factors. and separation from others. 4. the effects of drugs and treatments. and other tactile stimulation. Methods that are effective for contraception do not always reduce the risk of STDs. identify alternative. Take pain medication if needed. 26. contraception b. men (testicular exams) 22. Normal sexual changes occur as people age. 28. 2005 by Mosby. 25. prevention of STDs d. note behavioral cues 31.

d 5. prayer. and making offerings or sacrifices. involvement in a spiritual community. Inc. 16. sacraments. g 7. Individuals who accept change in life. the strength of a client’s spirituality influences how he or she copes with sudden illness and how quickly he or she moves to recovery b. 12. readiness for enhanced spiritual well-being. an affiliate of Elsevier Inc. patterns reflect a person’s actual or potential dispiritedness Mosby items and derived items © 2009. f 4. oneself. Remaining connected with their cultural heritage often helps clients define their place in the world and to express their spirituality. a. Rituals include participation in worship. family or friends. 14. i 11. 20. spiritual distress. or a combination) and guidance in their lives that lead them to choose and act on their beliefs. living in the moment and not worrying about tomorrow. as an awareness of one’s inner self and a sense of connection to a higher being. nature. Individuals have some source of authority (supreme being. e 3. education. this along with the loss of a sense purpose in life impairs the ability to cope with alterations in functioning c. 18. a type of relationship that an individual has with other persons 19. appreciating nature. code of conduct. 21. a 10. make decisions about their lives. future events 13. meditating. creates an uncertainty about what death means and thus makes clients susceptible to spiritual distress d. c 8. dependence on others for routine self-care needs often creates feelings of powerlessness. . scripture reading. expressing love toward others. or to some purpose other than oneself 2. 2005 by Mosby. and being productive. Belief system. more energy is available to deal with new difficulties and to resolve problems.Study Guide Answer Key Chapter 29: Spiritual Health 60 1. When people are satisfied with life. singing. show a person’s ability to experience and integrate meaning and purpose in life through connectedness with self and others 22. 15. psychological phenomenon of people who either have been close to clinical death or have recovered after being declared dead. Expression of spirituality is highly individual and includes showing an appreciation for life in the variety of things that people do. fasting. 17. a specific religious leader. and are able to forgive others in times of difficulty have a higher level of spiritual well-being.. others. lifestyle. h 9. People who are connected to themselves. b 6. nature. and God or another supreme being cope with the stress brought on by crisis and chronic illness. ethics or values.

39. spiritual visitations. Must be able to practice the five pillars of Islam. renewing. risk for spiritual distress. 33. as well as the client b. Food and rituals are sometimes important to a person’s spirituality. maintaining. Inc. Their belief is not to kill any living creature. have poor relationships. and enhances the function of the immune system 32. emotional. focused way that is either highly ritualized and formal or spontaneous and informal 31. listening and having a positive and encouraging (but realistic) attitude. assisting the client in using social. or what was perceived as God. 2. giving attention. reveal the client developing an increased or restored sense of connectedness with family. 30. they often report an increased spirituality that they commonly describe as experiencing the presence of power. a. slows the aging process. 2. finding an interpretation or understanding of the illness. the nurse. or attendance at religious services. 28.. the client will express an acceptance of his or her illness b. health and spirituality are connected 35. 36. When clients use meditation in conjunction with their spiritual beliefs. Muslims wash the body of the dead family member and wrap it in white cloth with the head turned to the right shoulder. serve as a human link connecting the client. force or energy.Study Guide Answer Key 61 23. answering questions. the client initiates social interactions with family and friends 25. pain. Figure 29-6 in the text Mosby items and derived items © 2009. 3. Plan care to allow time for religious readings. have experienced a recent loss. The defining characteristics reveal patterns that reflect a person’s actual or potential dispiritedness. an affiliate of Elsevier Inc. . mobilizing hope for the nurse. 2005 by Mosby. or who are suffering from some form of mental or physical illness 24. The nurse’s ability to enter into a therapeutic and spiritual relationship with the client will support a client during times of grief. and spiritual resources 27. 37. being with rather then doing for 26. reduces pain. offers an opportunity to renew personal faith and belief in a higher being in a specific. a. 3. lowers blood pressure. the client reports the ability to rely on family members for support c. anxiety. or reforming a sense of purpose in life and for a some a confidence and trust in a supreme being or power 34. The support system is a source of faith and hope and often is an important resource in conducting meaningful religious rituals. 38. or other stressful emotion that is acceptable to the client c. 3. 29. and the client’s lifestyle before an illness. creates a relaxation that reduces daily stress.

Inc. bargaining (make promises to God or loved ones) d. disorganization and despair (endlessly examines how and why the loss occurred) d. f 15. adjusts to the environment in which the deceased is missing d. reacts to. a. j 10. accepts the reality of the loss b. o 3. g 6. an affiliate of Elsevier Inc. reminiscing (telling and retelling stories) d. b 8. readjusts and reinvests 21. l 7. and lonely) e. hopeless. m 2. . e 11. anger (adjustment to loss. k 9. reorganization (accepts change. yearning and searching (for the lost person or object) c.. relinquishes old attachments e. a grieving person comes to recognize the loss b.Study Guide Answer Key Chapter 30: The Experience of Loss. and Grief 62 1. Mosby items and derived items © 2009. works through the pain of grief c. a. depression (sad. 2005 by Mosby. and expresses the pain of separation c. person expresses resistance and feels intense anger at others) c. 17. a 16. a. emotionally relocates the deceased and moves on with life 20. experiences. denial (a person acts as though nothing has happened and refuses to accept the fact of the loss) b. p 5. i 12. Death. assumes roles. a. acceptance (person incorporates the loss into life and finds ways to move forward) 18. n 4. numbing (stunned or unreal) b. acquires new skills) 19. h 14. d 13.

offer a support system to help families cope g. promote spiritual comfort and hope g. the nature of the family relationships. protect against abandonment and isolation h. readiness for enhanced comfort c. support efforts to adjust to the loss. encourage establishment of new relationships 63 Mosby items and derived items © 2009. or soothing of symptoms of disease or disorders throughout the entire course of an illness. enhance the quality of life 27. human development b. spiritual and religious beliefs h. reduction. death anxiety b. help the survivor accept that the loss is real 29. promote dignity and self-esteem e. using a problem-solving approach 30. will participate in treatment decisions b. including care of the dying and bereavement follow-up for the family 26. availability of support systems 23. . personal relationships c. culture and ethnicity g. nature of the loss d. Inc. ineffective denial d. cultural and spiritual beliefs. relief. will be able to continue parental responsibilities in care of toddler c. is the prevention. readiness for enhanced spiritual well-being 24. hope 22. hopelessness f. provide psychosocial care c. use therapeutic communication b. a. sources of hope.Study Guide Answer Key a.. neither hasten nor postpone death c. personal goals. assist with end-of-life decision making 28. a. provide relief from pain and other distressing symptoms d. client’s coping style. coping strategies e. an affiliate of Elsevier Inc. a. maintain a comfortable and peaceful environment f. a. fear e. spiritual distress g. will communicate treatment side effects or concerns to the health care team 25. offer a support system to help clients live as actively as possible until death f. support the grieving family i. manage symptoms d. affirm life and regard dying as a normal process b. integrate psychological and spiritual aspects of client care e. 2005 by Mosby. socioeconomic status f.

surgical dissection of a body after death to determine the cause and circumstances of death or discover the pathway of a disease 38. an affiliate of Elsevier Inc. medical and nursing services. and how donation will affect burial or cremation 37. 1. physician-directed services. 2005 by Mosby. is to help clients and families achieve the best possible quality of life. client and family are the unit of care. Inc. maintaining the integrity of rituals and mourning practices 39. allow time to grieve 32. control of symptoms. renewed or new personal relationships. cushions and postpones awareness of the loss by trying to prevent it from happening 44. the care of the body after death. 3. improved energy level. and decrease of inner pain 41. provision of an interdisciplinary care team. return of a sense of humor and normal life patterns.Study Guide Answer Key 64 31. care of the terminally ill client and their families 43. be alert for signs of ineffective. which organs or tissues can be donated. 3. which are learned as change always involves necessary losses. coordinate home care with access to available nursing home beds. provide continuing support 34. use of trained volunteers for frequent visitation. provides information about who can legally give consent. 2. 42. bereavement follow-up. associated costs. Figure 30-6 in your text Mosby items and derived items © 2009. Life changes are natural and often positive. . and finding it easier to be around people 40. normalized sleep and dietary patterns. improved ability to make decisions. reorganization of life patterns. harmful coping mechanisms 35. talking about the loss without feeling overwhelmed. acceptance into the program based on need 36. interpret normal behavior 33.. determining the goals of care and selection of the appropriate interventions 45.

adolescent (identity). arises frrm job changes (one’s own or family) and relocation 25. an affiliate of Elsevier Inc. g 6. characteristics of the handshake d. 2005 by Mosby. r 10. increasing the level of well-being of an individual or group. secondary. grooming and hygiene b. b 19. and tertiary prevention focus on avoiding negative events 24. t 21. i 15. q 13..Study Guide Answer Key Chapter 31: Stress and Coping 65 1. vary with life stage: children (relate to physical appearance). loss of parents and caregivers (children). l 20. j 2. a. a 16. p 11. perception of the stressor b. gait c. o 9. k 4. and tertiary prevention) 23. adherence to healthy practices 28. the reticular formation c. medulla oblongata b. c 3. secondary. poverty and physical handicaps. preadolescent (selfesteem issues). h 18. actions while sitting e. a. n 8. s 14. homelessness 27. . quality of speech Mosby items and derived items © 2009. primary. f 7. views nursing as being responsible for developing interventions to prevent or reduce stressors on the client or to make them more bearable for the client (focus is on primary. maladaptive coping used c. e 17. adults (major changes in life circumstances) 26. m 5. d 12. a. Inc. violence. the pituitary gland 22.

more directive 34. effective coping b. 1. Neurophysiological responses to stress function through negative feedback. support systems c. 1. 36. a. Inc. family coping c. and ability to concentrate have improved 35. learn skills that reduce physiological response to stress 32. 2005 by Mosby. resistance stage.Study Guide Answer Key 66 f. stress management in the workplace 33. appetite. a. caregiver emotional health d. sleep patterns. The nurse helps the client make the mental connection between the stressful event and the client’s reaction to it. . 1. 3.. increase resistance to stress c. a. 39. verbalization of an inability to cope and an inability to ask for help 30. psychosocial adjustment: life change 31. Figure 31-8 in your text Mosby items and derived items © 2009. 37. the attitude of the client 29. decrease stress-producing situations b. and the exhaustion stage 38. journal writing h. regular exercise b. alarm reaction. progressive muscle relaxation f. reports of feeling better when the stressor is gone. guided imagery and visualization e. eye contact g. an affiliate of Elsevier Inc. Stress is an experience a person is exposed to through a stimulus or stressor. time management d. assertiveness training g. is a specific type of brief psychotherapy with prescribed steps.

4. verify and communicate significant changes 12.Study Guide Answer Key Chapter 32: Vital Signs 1. 2. h 26. an affiliate of Elsevier Inc. 5. age b. systematic approach 8. Equipment needs to be based on the client’s condition and characteristics. exercise c. fever spikes and falls without a return to normal d. environment 24. f 16. h 14. a 32. 3. hormone level d. The nurse may delegate the measurement of vital signs but is responsible for analyzing and interpreting their significance and select appropriate interventions. stress f. Equipment needs to be appropriate and functional. use measurements to determine the indications for medication administration 10. a constant body temperature continuously over 38 degrees C that has little fluctuation b. b 27. periods of febrile episodes and periods of acceptable temperature values 67 Mosby items and derived items © 2009. . c 22. Know the client’s usual range of vital signs. Control or minimize environmental factors. 2005 by Mosby. develop a teaching plan 13. 6. a. g 30. i 21. e 17. a 18. d 31. Inc. a. d 23. c 29. j 15. Know the client’s medical history. e 25.. g 19. f 28. analyze the results 11. collaborate with health care providers to decide on the frequency 9. 7. fever spikes interspersed with usual temperature levels c. b 20. circadian rhythm e.

Study Guide Answer Key 33. Examples of answers can be found in the Box 32-5. 34. a. subtract 32 from the Fahrenheit reading and multiply the result by 5/9 b. multiply the centigrade reading by 9/5 and add 32 to the product 35. a. risk for imbalanced body temperature b. hyperthermia c. hypothermia d. ineffective thermoregulation 36. a. attaining fluid and electrolyte balance within 24 hours b. obtaining appropriate clothing to wear in cold weather 37. very young and very old, trauma, stroke, diabetes, drug or alcohol intoxication, sepsis, inadequate home heating and shelter, fatigue, skin color, malnutrition, hypoxemia 38. a. have immature temperature-control mechanisms and temperatures can rise rapidly and are at risk for fluid-volume deficit b. often accompanied by other allergy symptoms such as rash or pruritus 39. a. nonsteroidal drugs and corticosteroids b. tepid sponge baths, bathing with alcohol water solutions, applying ice packs to axillae and groin sites, and cooling fans 40. Move the client to a cooler environment, remove excess body clothing, place cool wet towels over the skin, and use fans. 41. Remove wet clothes; wrap the client in blankets 42. After each intervention measure the client’s temperature to evaluate for change, palpate the skin, and assess the pulse and respirations. 43. a. radial b. apical 44. Refer to Table 32-2 for answers. 45. a. rate, rhythm, strength, and equality b. rate and rhythm only 46. a. 120-160 b. 90-140 c. 80-110 d. 75-100 e. 60-90 f. 60-100 47. See answers in Table 32-4. 48. abnormal elevated heart rate, above 100 beats per minute in adults 49. slow rate, below 60 beats per minute in adults


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Study Guide Answer Key


50. an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral site; the difference between the apical and the radial pulse rate 51. An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm. 52. movement of gases in and out of the lungs 53. the movement of oxygen and carbon dioxide between the alveoli and the red blood cells 54. the distribution of red blood cells to and from the pulmonary capillaries 55. low levels of arterial O2 56. a. active b. passive 57. See Table 32-11 for answers. 58. a. 30-60 b. 30-50 c. 25-32 d. 20-30 e. 16-19 f. 12-20 59. Rate of breathing is regular but slow; < 12 breaths per minute. 60. Rate of breathing is regular but rapid; > 20 breaths per minute. 61. Respirations are labored, increased in depth, and rate is > 20 breaths per minute. 62. Respirations cease for several seconds. 63. Rate and depth of respirations increase. 64. Respiratory rate is abnormally low, and depth of ventilation is depressed. 65. Respiratory rate and depth are irregular; alternating periods of apnea and hyperventilation. 66. abnormally deep, regular, and increased in rate 67. abnormally shallow for 2-3 breaths followed by irregular period of apnea 68. The percent of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin, usually between 95% and 100%. 69. the force exerted on the walls of an artery by the pulsing blood under pressure from the heart 70. peak of maximum pressure when ejection occurs 71. When the ventricles relax, the blood remaining in the arteries exerts a minimum pressure. 72. the difference between systolic and diastolic pressure 73. increases as a result of an increase in heart rate, greater heart muscle contractility, or an increase in blood volume 74. is the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels 75. the volume of blood circulating (increased or decreased) affects the blood pressure 76. the thickness affects the ease with which blood flows through blood vessels, determined by the hematocrit

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77. With reduced elasticity there is greater resistance to blood flow and the systemic pressure rises (systolic pressure). 78. a. age b. stress c. ethnicity d. gender e. daily variations f. medications g. activity and weight h. smoking 79. a. 40 (mean) b. 85/54 c. 95/65 d. 105/65 e. 110/65 f. 120/75 g. <120/80 80. See Table 32-8. 81. family history, obesity, cigarette smoking, heavy alcohol consumption, high sodium, sedentary lifestyle, exposure to continuous stress, diabetics, older, African Americans 82. dehydrated, anemic, experienced prolonged bed rest, recent blood loss, medications 83. 1st – clear, rhythmical tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure) 2nd – blowing or swishing sound as the cuff deflates 3rd – a crisper and more intense tapping 4th – muffled and low-pitched as the cuff is further deflated (diastolic pressure in infants and children) 5th – the disappearance of sound (diastolic pressure in adolescents and adults) 84. palpation technique; usually occurs between the first and second Korotkoff sounds 85. See Table 32-17 for answers. 86. See Table 32-18 for answers. 87. 4. The skin regulates the temperature through insulation of the body, vasoconstriction, and temperature sensation. 88. 3. is the transfer of heat from one object to another with direct contact (solids, liquids, and gases) 89. 3. Victims of heat stroke do not sweat. 90. 2. 156 is the onset of the first Korotkoff sound (systolic pressure) and 88 is the fifth sound that corresponds with the diastolic pressure.

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signs of distress 12. compare each area inspected with the same area on the opposite side e. confirm. and Mrs. a. and density of underlying structures to verify abnormalities assessed 5. perform the exam near bathroom facilities g. posture Mosby items and derived items © 2009. speak alone with them 8. size. pay attention to detail 3. a. sensory or physical limitations (more time) c. an affiliate of Elsevier Inc. use open-ended questions to allow parents to share more information f. gather baseline data about the client’s health status b. make clinical judgments about a client’s changing health status e. a. 2005 by Mosby. psychological preparation of the client 7. a. and abnormalities d. position.. adequate space is needed d. color. do not hurry. body type 13. inspect each area for size. use patience. supplement. gather all or part of the histories of infants and children from parents b. which determines the location. call children by their first name and address the parents as Mr. do not stereotype b. produces a vibration that travels through the body tissues. a. . equipment d. confirm and identify nursing diagnoses d. evaluate the outcomes of care 2. age 11. perform the examination in a nonthreatening area c. e. involves the use of the hands to touch body parts to make sensitive assessments 4. treat adolescents as adults g. environment c. confidentiality for adolescents. shape. offer support to the parents during the examination d. Inc. infection control b. be alert for signs of increasing fatigue 9. position and expose body parts to be viewed c. use additional lighting to inspect body cavities f. physical preparation of the client e. or refute data c.Study Guide Answer Key Chapter 33: Health Assessment and Physical Examination 71 1. symmetry. certain types of information may be stressful to give f. allow for pauses e. adequate lighting is available b. involves listening to sounds the body makes with the use of a stethoscope 6. gender and race 10.

Study Guide Answer Key


14. gait 15. body movements 16. hygiene and grooming 17. dress 18. body odor 19. affect and mood 20. speech 21. physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising); fear of the spouse or partner, caregiver, or parent 22. C – have you ever felt the need to cut down on your use? A – have people annoyed you by criticizing your use? G – have you ever felt bad or guilty about your use? E – have you ever used or had a drink first thing in the morning as an eye-opener to steady your nerves or feel normal? 23. a. need to weigh clients at the same time of day b. on the same scale c. in the same clothes to allow an objective comparison of subsequent weights 24. trauma to skin during care, exposure to pressure during immobilization, reaction to various medications , neurologically impaired, chronically ill and orthopedic clients, diminished mental status, poor tissue oxygenation, low cardiac output, or inadequate nutrition 25. aggressive form of skin cancer 26. discolored skin that occurs unevenly, especially in the older adult 27. Answers can be found in Table 33-10. 28. a. eczema b. dermatitis 29. hardened 30. skin’s elasticity 31. areas of the skin swollen or edematous form a buildup of fluid in the tissues 32. thickening of the skin 33. ruby-red papules 34-42. Answers can be found in Box 33-8. 43. a. pediculus humanus capitis (head lice) b. pediculus humanus corporis (body lice) c. pediculus pubis (crab lice) 44. change in the angle between nail and nail base, softening and flattening and enlargement of the fingertips 45. transverse depressions in nails 46. concave curves 47. splinter hemorrhages 48. inflammation of the skin at base of the nail 49. congenital anomaly or the buildup of cerebrospinal fluid in the ventricles

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50. enlarged jaws and facial bones 51. a refractive error causing farsightedness 52. a refractive error causing nearsightedness 53. impaired near vision in middle-age and older adults, caused by loss of elasticity of the lens 54. noninflammatory eye disorder resulting from changes in retinal blood vessels 55. congenital condition in which both eyes do not focus on an object simultaneously 56. increased opacity of the lens 57. intraocular structural damage resulting from increased intraocular pressure 58. blurred central vision often occurring suddenly, caused by progressive degeneration of the center of the retina 59. a. visual acuity b. visual fields c. extraocular movements d. external eye structures e. internal eye structures 60. a. position and alignment b. eyebrows c. eyelids d. lacrimal apparatus e. conjunctivae f. sclerae g. pupils and irises 61. bulging eyes 62. lid margins that turn out 63. lid margins that turn in 64. presence of redness, which indicates and allergy or an infection 65. a thin white ring along the margin of the iris 66. Pupils Equal, Round, Reactive to Light and Accommodation 67. retina, choroids, optic nerve disc, macula, fovea centralis, and retinal vessels 68. a. external (auricle, outer ear canal and tympanic membrane) b. middle (3 bony ossicles) c. inner ear (cochlea, vestibule, and semicircular canals) 69. a. enter the external ear, pass through the outer ear canal b. waves reach the tympanic membrane (vibrate) c. vibrations are transmitted through the middle ear by the bony occicular chain to the oval window of the inner ear d. cochlea receive the vibration e. nerve impulses from the cochlea travel to the auditory nerve (8th) and to the cerebral cortex 70. a. conduction

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b. sensorineural c. mixed 71. lateralization of sound equally in both ears 72. comparison of air and bone conduction (AC>BC) 73. skin breakdown, characterized by redness and skin sloughing 74. tumor-like growths 75. thick white patches that are often precancerous lesions seen in heavy smokers and alcoholics 76. swollen, tortuous veins that are common in the older adult 77. extra bony growth between the 2 palates 78. neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea 79. sound waves that create vibrations that can be palpated externally 80. air movement through smaller airways that is soft, breezy, and low-pitched 81. air moving through larger airways that is blowing, medium-pitched, and intensity 82. air moving through trachea which is loud and high-pitched, with hollow quality 83. Answers can be found in Table 33-22. 84. apex touching the anterior chest wall at approximately the fourth to fifth intercostal space, just medial to the left midclavicular line 85. Mitral and tricuspid valve closure causes the first heart sound. 86. Aortic and pulmonic valve closure causes the second heart sound. 87. rapid ventricular filling 88. Atria contract to enhance ventricular filling. 89. lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch 90. second intercostal space on the right 91. left second intercostal space 92. left third intercostal space 93. Fourth or fifth intercostal space along the sternum 94. Fifth intercostal space just to the left of the sternum, left midclavicular line 95. tip of the sternum 96. sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase 97. a. auscultate all valve areas for placement in the cardiac cycle (timing), where best heard (location) and radiation, loudness, pitch and quality b. between S1 and S2 (systolic) and S2 and S1 (diastolic) c. location is not necessarily over the valves d. assess for radiation e. intensity or loudness and record in grading 1-6 f. low-pitched murmur best heard with the diaphragm 98. caused by a drop in heart rate and blood pressure 99. absent pulse wave (blockage) 100. diminished or unequal carotid pulsations 101. blood passing through a narrowed section, creating turbulence 102.

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use 2 rulers e. movement decreasing angle between 2 adjoining bones 126. hard lump on the side of the testicle 119. or fluid in the abdominal cavity 111. absent sounds that may indicate a lack of peristalsis 113. 75 semi-Fowler’s position expose the neck. sometimes with nipple discharge 108. increasing angle between 2 adjoining bones 127. painful breast. that the frontal or ventral surfaces face downward 129. metabolic bone disease that causes a decrease in quality and quantity of bone 124. rotation of the joint inward 133. 105. lateral spinal curvature 123. small. to detect colorectal cancer in the early stages and prostatic tumors 120. which appear as small. localized dilation of a vessel wall 116.open ulcers that drain serous material 117. away from the midline 131. align the head lean client back into a supine position. syphilitic lesions. 104. spreading to the nodes 107. family history: need a yearly exam e. toward the midline 132. and swelling over vein sites. mammogram: age 40 annually (asymptomatic) f. an increased lumbar curvature 122.Study Guide Answer Key a. swayback. swelling by intestinal gas. tumor. occurs in clients with peritoneal irritation 115. rotation of the joint outward 134. .. c. which are hyperactive bowel sounds 114. a. stretch marks 109. bilateral lumpy. protusion of abdominal organs through the muscle wall 110. front or ventral surface faces upward 130. Refer to Table 33-26 for the answers. growling sounds. which is a normal function of the small and large intestine 112. turning of the body part away from the midline Mosby items and derived items © 2009. BSE monthly b. additional testing (increased risks) 106. tenderness. clinical breast exam every 3 years (20-40) and yearly over the age of 40 d. b. repeat the same measurement on the other side 103. women aged 20 years and older need to report any breast changes c. beyond its normal resting extended position 128. movement of contents through the intestines. 2005 by Mosby. a painless enlargement of one testis and the appearance of a palpable. Inspect the calves for localized redness. level of venous pulsations begin to rise as the patient reaches 45-degree angle d. a test for cervical and vaginal cancer 118. hunchback. an affiliate of Elsevier Inc. an exaggeration of the posterior curvature of the thoracic spine 121. Inc. measures the precise degree of motion in a particular joint 125.

measures orientation and cognitive function 142. hypoglossal 146. smaller than 1 cm 153. facial h. glossopharyngeal j. a muscle with little tone 140. 2. circumscribed elevation of skin filled with serous fluid. a. 3. high-velocity airflow through severely narrowed or obstructed airway 155. Inc. auditory i. 4. an affiliate of Elsevier Inc. Mosby items and derived items © 2009. abducens g. trochlear e. cutaneous reflexes (plantar. confusion. temperature. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite of the body. After the ventricles empty. 2-point discrimination 148. 2005 by Mosby. vagus k. the back of the hand is not the best place to test for turgor 152. deep tendon reflexes (biceps. increased muscle tone 139. 3. optic c.Study Guide Answer Key 76 135. a.. and restlessness 143. an objective measurement of consciousness on a numerical scale over time 144. and crude and finely localized touch 147. Achilles) b. disorientation. spinal accessory l. position. a. flexion of toes and foot upward 137. Muscular activity maintains balance and equilibrium and helps to control posture. a person cannot understand written or verbal speech b. allowing the valves to close and causing the second heart sound. trigeminal f. ventricular pressure falls below that in the aorta and pulmonary artery. A thorough explanation of the purpose and steps of each assessment lets clients know what to expect and what to do so that they can cooperate. light touch. gluteal. 151. 149. Use a systematic pattern when comparing the right and left sides. . triceps. abdominal) 150. patellar. bending of toes and foot downward 138. pain. olfactory b. vibration. 154. vibration. normally the skin lifts easily and snaps back immediately to its resting position. 4. 3. a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate 145. pain. oculomotor d. position. a muscle reduced in size that feels soft and boggy 141. turning the body part toward the midline 136.

airborne – droplets that suspend in air 22. and the intestinal walls and GU tract that maintain health.. d 2. j 12. c 16. 2005 by Mosby. eyes. p 9. The skin. g 6. or purulent. a portal of exit from the reservoir d. k 8. urinary tract. l 5. direct – person-to-person or physical source and susceptible host 19. Inc. Mosby items and derived items © 2009. sanguineous. h 15. an infection that affects the entire body instead of just a single organ 26. m 3. a. Exudate may be serous. 27. o 4. the body’s response to injury. The body contains microorganisms that reside on the surface and deep layers of the skin. vector – internal and external transmissions 24. droplet – large particles that travel up to 3 ft and come in contact with the host 21. mouth. respiratory tract. b 13. e 14. blood products. wound infection. or irritation. depends on the individual degree of resistance to a pathogen (immune response) 25. a. acute inflammation: rapid vasodilatation that causes redness at the site and localized warmth allowing phagocytosis to occur 30. patient experiences localized symptom b. n 7. in saliva and oral mucosa. an infectious agent or pathogen b. GU tract. 28. and vagina have unique defenses against infection. and nutrients to an area of injury 29. accumulation of fluid and dead tissue cells and WBCs forms at the site. indirect – personal contact of susceptible host with contaminated inanimate object 20. a portal of entry to a host f. i 17.Study Guide Answer Key Chapter 34: Infection Prevention and Control 77 1. is a protective vascular reaction that delivers fluid. a susceptible host 18. a 10. an affiliate of Elsevier Inc. a reservoir or source c. . a mode of transmission e. f 11. vehicles –contaminated items 23. infection.

cleaning the environment routinely 49. control portals of exit and entry 47. and maturative stages. educating the client and family about infection control techniques 46. impaired tissue integrity 45. a. preventing exposure to infectious organisms b. diabetes 40. heart disease.Study Guide Answer Key 78 31. avian flu. .. imbalanced nutrition c. immunizations c. Healing involves the defensive. diabetes 36. 32. the technique refers to the practices/procedures that assist in reducing the risk for infection 48. the complete elimination or destruction of all microorganisms. an affiliate of Elsevier Inc. Inc. clean technique: hand hygiene. removal of all soil (organic and inorganic material) from objects and surfaces with the use of water and mechanical action with detergents or enzymatic products 50. surgical or traumatic wounds c. a process that eliminates many or all microorganisms with the exception of bacterial spores from inanimate objects 51. internal bleeding 42. respiratory tract d. transplant 39. 44. controlling or reducing the extent of infection c. anorexia 43. a. impaired oral mucous membrane d. ineffective tissue perfusion f. homeless 38. West Nile virus. invasive radiology. a. maintaining resistance to infection d. comes from microorganisms outside the individual that do not exist in normal floras 33. sickle cell disease. hantavirus 41. eliminate reservoirs of infection f. urinary tract b. exposure to communicable/infectious disease. nutrition b. fractures. See Table 34-5 for answers. use of IV drugs/substances 37. unemployed. including spores Mosby items and derived items © 2009. SARS. occurs when part of the client’s flora becomes altered and an overgrowth results 34. personal hygiene d. using clean gloves. bloodstream 35. strengthen their defenses a. regular rest and exercise e. the absence of pathogenic microorganisms. risk for infection b. obesity. miner. impaired skin integrity e. 2005 by Mosby. reconstructive. COPD.

. contaminated surface. 66. When a sterile surface comes in contact with a wet. based on the mode of transmission of disease that is termed airborne. a. droplet. during procedures that involve insertion of catheters 65. cultures b. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. prevent transmission of organisms through indirect and direct contact –use disinfectant on stethoscopes. Because fluid flows in the direction of gravity. applies to hand washing. gowns – to prevent soiling clothes during contact with the client 59. body fluid. when the skin’s integrity is broken c. antiseptic hand wash. Inc. a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the object’s surface. a. wound cleansing 55. during procedures that require intentional perforation of the client’s skin b. nonintact skin. droplet or airborne precautions 60. teach patient respiratory hygiene 54. 2005 by Mosby. an affiliate of Elsevier Inc. antiseptic hand rub. 70. Mosby items and derived items © 2009. need to eliminate sources of body fluids. discard contaminated articles 53. provide staff and client education b. 68. monitor antibiotic-resistant organisms 64. recommend appropriate isolation procedures d. Place only sterile objects on a sterile field 67. A sterile object or field becomes contaminated by prolonged exposure to air. contact. masks – when you anticipate splashing or spraying of blood or bloody fluid into the face. consult with health departments f. selected isolation material 63. protective environment 58. develop and review infection prevention and control policies and procedures c. pathological wastes c. the sterile object or field becomes contaminated by capillary action. blood and blood products d. . gloves – to prevent the transmission of pathogens by direct and indirect contact 62. IV tubing. consult with all departments to investigate unusual events or clusters i.handling of catheters and drainage sets. eyewear – procedures that generate splash or splatter 61. A sterile object remains sterile only when touched by another sterile object. drainage. soiled linens.Study Guide Answer Key 79 52. 69. notify the public health department of incidences of communicable diseases h. is designed for all clients in all settings regardless of the diagnosis. gather statistics regarding the epidemiology g. apply to contact with blood. or surgical hand antisepsis 56. sharps e. or solutions that may harbor organisms. and mucous membranes 57. screen client records e. a.

masks. and urinary tract b. invasive sites. preparing a sterile field e. Mosby items and derived items © 2009. erythema. Infection occurs in a cycle that depends on the presence of certain elements. donning a sterile gown 73. The incubation period is the interval between the entrance of the pathogen into the body and appearance of first symptoms. an affiliate of Elsevier Inc. respiratory tract. all invasive and surgical sites for swelling. a. surgical scrub c. or purulent drainage c. 72. review lab results 74. 3. pouring sterile solutions g. 78. 76. a. and eyewear d. monitor clients postoperatively –surgical sites. assemble all equipment b. occurs when part of the client’s flora becomes altered and an overgrowth results 77.Study Guide Answer Key 80 71. applying sterile gloves h. . 1. Inc. open sterile packages on a flat surface f. monitor breath sounds d. donning caps. 2005 by Mosby. 4. 75. 1.. organisms can travel to the sterile object. Clients who are transported outside of their rooms need to wear a surgical mask to protect other clients and personnel. The edges of a sterile field or container are considered to be contaminated. If moisture leaks through a sterile package’s protective covering. 1.

are predictable responses to a medication 19. 2. the kidneys. blood flow to the site of administration d. 22. route of administration b. Currently the FDA ensures that all medications undergo vigorous testing before they are sold.. a client is at risk for medication toxicity 13. constant blood level within a safe therapeutic range 23. and severe wheezing and shortness of breath 20. are severe responses to medication 16. edema of the pharynx and larynx. and remove biologically active chemicals. manufacturer who first develops the medication. determines its route of administration 7. protein binding 11. degrade. when renal function declines. a. and exit the body 8. when one medication modifies the action of another medication 21. occurs under the influence of enzymes that detoxify. 2005 by Mosby. which becomes the official name 4. lipid solubility 10. Inc. is the expected or predictable physiological response to a medication 14. unpredictable effects in which a client overreacts or underreacts to a medication or has a reaction different from normal 18. allergic reactions that are life-threatening and characterized by sudden constriction of bronchiolar muscles. is the study of how medications enter the body. are the unintended. a. a.Study Guide Answer Key Chapter 35: Medication Administration 81 1. time it takes for a medication to reach its highest effective concentration Mosby items and derived items © 2009. b. The combined effect of the 2 medications is greater than the effect of the medications when given separately. the symptoms the medication relieves. individual policies to meet federal and state regulations. indicates the effect of the medication on a body system. d. secondary effects a medication predictably will cause 15. provides an exact description of the medication’s composition and molecular structure 3. time it takes after a medication is administered for it to produce a response 26. circulation b. is to protect the health of the people by ensuring that medications are safe and effective. highest serum concentration 24. mostly in the liver 12. ability of the medication to dissolve c. is the time it takes for excretion processes to lower the serum medication concentration by half 25. metabolize. define the scope of a nurse’s professional functions and responsibilities. body surface area e. reach their site of action. an affiliate of Elsevier Inc. the manufacturer has trademarked the medication’s name 5. membrane permeability c. c. or the medication’s desired effect 6. . refers to the passage of medication molecules into the blood from the site of administration 9. develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion 17. conform to federal legislation but also have additional controls such as alcohol and tobacco.

metric b. spraying 41. reconcile d. irrigating a body cavity e.7 m2 x normal adult dose 46. the right documentation 56. directly into the arteries 38. the right client d. action. commonly chemotherapeutics 37. household 43. a. be informed of the medication’s name. transmit 55. They are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue. oral b. the right dose c. a. intradermal b. a. intravenous 32. nurse has up to 90 minutes to administer 52. receive labeled medications Mosby items and derived items © 2009. administered in the epidural space via a catheter. is used when a client needs a medication quickly but not right away. directly into the pleural space. the right route e. intramuscular d. and antibiotics 36. a. instilling fluid into a body cavity d. clarify c. Inc. subcutaneous c. a.Study Guide Answer Key 82 27. single dose of a medication to be given immediately and only once 51. sublingual 31. injection of a medication into a joint 40. an affiliate of Elsevier Inc. blood serum concentration of a medication reached and maintained after repeated fixed doses 30. insulin. the right time f. a medication that is given only once at a specified time 50. a. giving the medication using the wrong route or time interval. administration of the wrong medicine. child’s dose = surface of child/1. injection directly into the cardiac tissue 39. a. 2005 by Mosby. minimum blood serum concentration of medication reached just before the next scheduled dose 28. have qualified nurses or physicians assess a medication history d. be properly advised of the experimental nature of medication therapy and give written consent e. a medication that is given only when a client requires it 49. a. dose ordered/dose on hand x amount on hand = amount to administer 45. verify b. directly applying a liquid or ointment b. inaccurate prescribing. if the order is given verbally to the nurse by the provider 47. time during which the medication is present in concentration great enough to produce a response 29. purpose. . 42. commonly used in infants and toddlers 35. is carried out until the prescriber cancels it by another order or until a prescribed number of days elapse 48. a catheter that is in the subarachnoid space or one of the ventricles of the brain 34. automated medication dispensing systems (AMDS) 53.. unit dose b. and potential undesired effects b. apothecary c. and administering extra doses or failing to administer a medication 54. usually used for post-op analgesia 33. the right medication b. given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid 44. into the peritoneal cavity such as chemotherapeutic agents. infusion of medication directly into the bone marrow. inserting a medication into a body cavity c. refuse a medication regardless of the consequences c. buccal c.

symptoms. happens when people take more medications then needed 72. client’s learning needs 58. Prepare oral medications in the form that is easiest to swallow. disturbed visual sensory perception 64. client and family understand medication therapy b. signature of provider 70. Time medications to coincide with mealtimes or when the client is well-rested and awake if possible. l. c. . health beliefs. k. which increases the risk of aspiration. when clients need to take several medications to treat their illnesses b. date and time that the order is written c. f. receive appropriate supportive therapy g. effective therapeutic regimen management 66. ineffective 60. client’s full name b. ineffective therapeutic regimen management 67. a. to monitor blood sugar to determine if medication is appropriate to take d. If the client has unilateral weakness. history of allergies c. health-seeking behaviors 61. and habits 69. anxiety 59. medication name d. Determine the client’s ability to swallow. Thicken regular liquids or offer fruit nectars if the client cannot tolerate thin liquids.. and the exact time of administration and site 71. Mosby items and derived items © 2009. a. Allow the client to self-administer medications if possible. socioeconomic factors. dose e. b. Inc. will verbalize understanding of desired effects and adverse effects of medications b. a. personal motivations. history b. the name of the medication. client’s attitude about medication use h. deficient knowledge 62. d. i. client’s current condition g. route. a. and treatment of hypoglycemia c. a.Study Guide Answer Key 83 safely without discomfort f. Avoid straws because they decrease the control the client has over volume intake. client’s perceptual coordination problems f. noncompliance 63. client safely self-administers medications 73. Administer pills one at a time. establish a daily routine that will coordinate timing of medication with meal times 68. an affiliate of Elsevier Inc. g. impaired swallowing 65. time and frequency of administration g. be informed if medications are a part of a research study 57. diet history e. not receive unnecessary medications h. Assess the client’s cough. ensuring that each medication is properly swallowed before the next one is introduced. health maintenance. h. a. Administer medications using another route if risk of aspiration is severe. medication data d. 2005 by Mosby. Have client hold cup and drink from cup if possible. e. client’s knowledge and understanding of medication therapy i. place the medication in the stronger side of the mouth. route of administration f. Determine the presence of a gag reflex. dose. j. will state signs.

a. maintain aseptic technique 88. exerting local effects (promoting defecation) or systemic effects (reducing nausea) 80. and duration of action 89. 90 degrees 95. the outer posterior aspect of the upper arms.. Avoid touching length of plunger or inner part of barrel. intermediate. assess if patient has an existing patch before application c. 1 ml Mosby items and derived items © 2009. ensure that the final dose is accurate c. inject rapid-acting insulin mixed with NPH within 15 minutes before a meal e. 0. never allow a client to use another client’s eye medications 77. a. a. 85. a. rate of action (rapid. select the proper injection site d. a. do not mix phosphate-buffered insulins with lente insulins 90. contain single doses of medications in a liquid b. powdered medication and create an aerosol when the client inhales through a reservoir that contains the medication 81. 5/8 inch needle inserted at a 45-degree angle or a ½ inch needle inserted at a 90-degree angle 94. short. avoid touching the eyelids or other eye structures with eye droppers or ointment tubes c. decongestant spray or drops 76. . document removal of medication on the MAR 75. type of tissue into which the medication is to be injected 86. a. dizziness. use medication only for the client’s affected eye d. Prepare skin. document where the medication was placed on the MAR b. assess the skin thoroughly d. 25-gauge. apply a noticeable label to the patch f. jellies. never mix insulin glargine or insulin detemir with other types of insulin d. 3 ml into a large muscle b. a. 82. 2 ml c. and the anterior aspects of the thighs 92. each has a different onset.5 to 1 ml 93. Draw medication from ampule quickly. do not contaminate one medication with another b. inject the medication slowly and steadily 91. and long-acting). Inc.Study Guide Answer Key 84 74. the client’s size and weight b. a. Avoid letting needle touch contaminated surface. or creams 79. delivers a measured dose of medication with each push of a canister often used with a spacer b. avoid instilling any eye medication directly onto the cornea b. 2005 by Mosby. 84. nausea 78. use friction and a circular motion while cleaning with an antiseptic swab. is a single dose or multidose container with a rubber seal at the top (closed system) 87. 83. do not mix insulin with any other medication or diluents c. use a sharp beveled needle in the smallest suitable length and gauge b. hold the syringe while the needle remains in tissues g. a. and start from the center and move outward. do not mix short-acting and lente insulins unless the blood glucose levels are currently under control with this mixture f. foam. an affiliate of Elsevier Inc. divert the client’s attention from the injection e. suppositories. medication history/ reconciling medications e. the abdomen (below the costal margins to the iliac crests). vertigo. peak. position the client as comfortably as possible to reduce muscle tension c. hold dry. do not allow to stand open. need to maintain their individual routine when preparing and administering their insulin b. insert the needle quickly and smoothly f.

immunizations for children. an affiliate of Elsevier Inc. convenience. as mixtures within large volumes of IV fluids b. Inc. not used in infants or children. and toddlers (immunizations) 97. 1. older children. battery-operated and allows medications to be given in very small amounts of fluid (5-60 ml) 109. cost-saving. 3. recommended site for hepatitis B and rabies injections 99. frequently used in infants. a. minimizes local skin irritation by sealing the medication in muscle tissue 100.Study Guide Answer Key 85 96. 1. injected into the dermis where medication is absorbed slowly 101. most dangerous method because there is not time to correct errors b. preferred site for medications 98. small (25-100 ml) IV bag connected to a short tubing line to the lower Y port of a primary infusion 107.. a. safety. deep site away from nerves and blood vessels. less chance of contamination. if mixing rapid. use small amounts. absorption refers to the passage of medication molecules into the blood from the site of administration 112. Mosby items and derived items © 2009. a. 1. it allows for control of IV fluid intake 105. is an oral route 114. rapid absorption. a bolus may cause direct irritation to the lining of blood vessels 104. easily accessible but muscle not well developed. constant therapeutic blood levels 103. it reduces risk for rapid-infusion by IV push b. small (50-150 ml) containers that attach below the primary infusion bag 108. take insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn from the long-acting insulin first. easily identified landmarks. a. child’s dose = surface of child/1. piggyback infusion 102. . fast-acting medications must be delivered quickly b.7 m 2 x normal adult dose 115. definition of onset 113.or short-acting insulin with intermediate or long-acting insulin. increased mobility. potential for injury to radial and ulnar nerves. injection of a bolus or small volume of medication c. 2. allows for administration of medications that are stable for a limited time in solution c. 2005 by Mosby. definition of pharmacokinetics 111. a. and comfort for the client 110. lacks major nerves and blood vessels. skin testing. 2. a small (25-250 ml) IV bag connected to short tubing lines that connects to the upper Y port of a primary infusion line 106.

Direct needle manipulation of energetic meridians influences deeper internal organs by redirecting Chi. acupressure. Confucianism. Used to balance insulin and other hormones for optimal health. herbal remedies. Ayurveda: Traditional Hindu system of medicine practiced in India since the first century A. purgative. macrobiotic diet: Predominantly a vegan diet (no animal products except fish). European phytomedicines: Products developed under strict quality control in sophisticated pharmaceutical factories. include the same interventions as complementary but frequently become the primary treatment that replaces allopathic medical care 3. Mosby items and derived items © 2009. massage. carbohydrates. and 30% from fat. and rubbing oils that treat disease. Homeopathic medicine: System of medical treatments based on the theory that certain diseases can be cured by giving small doses of substances that in a healthy person would produce symptoms like those of the disease. includes botanical (plant) medicine. drugs.D. and certain chronic diseases such as hypercholesterolemia and coronary artery disease. activity. e. a. and avoidance of medications. an affiliate of Elsevier Inc. d. A combination of remedies such as herbs. b. which includes a humoral model for classifying food. herbal medicines. 4. Diet treats cancer. and illnesses and a series of folk illnesses.Study Guide Answer Key Chapter 36: Complementary and Alternative Therapies 86 1. a. the “Zone”: Dietary program that requires eating protein. vegetables. 40% from carbohydrates. Prescribed substances called remedies are made from naturally occurring plant. animal. schizophrenia. Recognizes inherent healing ability of the body. Qigong (balancing energy flow through body movement). and Buddhism. c. Fundamental concepts from Taoism. and unprocessed foods. b. Latin American practices: Curanderismo medical system. 2005 by Mosby. Treatments integrate traditional natural therapies with modern diagnostic science. massage. warmth. f. and oriental massage. Acupuncture: A traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of lines or channels. Traditional Chinese medicine: Set of systematic techniques and methods including acupuncture. and shamanic healing (healer makes contact with spirits to ask their direction in bringing healing to people). d. moxibustion (use of heat from burning herbs). . or mineral substances. c. packaged professionally in tablets or capsules. Emphasis placed on whole cereal grains. light. autism. Initially used in the management of a variety of cancers. and fat in a 30:40:30 ratio: 30% of calories from protein. Native American practices: Therapies include sweating and purging. Naturopathic medicine: System of therapeutics based on natural foods. orthomolecular medicine: Increased intake of nutrients such as vitamin C and beta-carotene. regular exercise. are therapies used in addition to conventional treatment recommended by the client’s provider 2. Inc. fresh air.. g. called meridians.

emotional. f. acupressure: Therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain. milk thistle. and interact. healing intention: Variety of techniques used in multiple cultures that incorporate caring. h. and social needs of individuals with disabilities and illnesses. or empathy with the target of prayer. movement. Ayurvedic herbs: Traditional Hindu system of herbs used for over 2000 years. and brain wave activity. or regulate a body function. e. a. traditional Chinese herbal medicines: Over 50. and give appreciation. breathwork: Using any of a variety of breathing patterns to relax. i. music therapy: Uses music to address physical.000 medicinal plant species. . dance therapy: Intimate and powerful medium for therapy because it is a direct expression of the mind and body. d. Mosby items and derived items © 2009. Inc. f. chiropractic medicine: System of therapy that involves manipulation of the spinal column and includes physiotherapy and diet therapy. skin temperature. psychological. foster self-awareness. Therapy stimulates the immune system and maintains external and internal balance. c. 6. simple touch: Touching the client in appropriate and gentle ways to make connection. b. behave. or physical problems. a.. Technique integrates the understanding of the physics of the body’s movement patterns with an awareness of the way people learn to move. b. Tai chi: Technique that incorporates breath. psychotherapy: Treatment of emotional and mental disorders by psychological techniques. Feldenkrais method: Alternative therapy based on establishment of good self-image through awareness and correction of body movements. develops emotional expression. produce analgesia. 5. Herbs have a wide variety of uses. through the use of instruments. biofeedback: A process providing a person with visual or auditory information about autonomic physiological functions of the body. Herbs considered the backbone of medicine. improve muscle tone. and bilberry. and distracts people who are in pain. cognitive. meditation: Self-directed practice for relaxing the body and calming the mind using focused rhythmic breathing g. e. invigorate. many of which have been studied extensively. massage therapy: Manipulation of soft tissue through stroking. and meditation to cleanse. such as muscle tension. or kneading to increase circulation. and circulate vital life energy and blood. e. d. rubbing. Therapy improves physical movement and/or communication. compassion. guided imagery: Therapeutic technique for treating pathological conditions by concentrating on an image or series of images. and express clients’ unspoken and frequently unconscious concerns about their disease. c. 2005 by Mosby. art therapy: Use of art to reconcile emotional conflicts. evokes memories. display acceptance. strengthen. Therapy treats persons with social. and relaxation. love. f. cognitive. an affiliate of Elsevier Inc.Study Guide Answer Key 87 Examples of well-studied herbal medicines include gingko biloba. or open emotional channels.

increased heart and respiratory rates. moves their hands in a rhythmic and symmetrical movement from Mosby items and derived items © 2009. yoga: Discipline that focuses on the body’s musculature. is the state of generalized decreased cognitive. low self-esteem. sleep disorders 16. fearing loss of control. increased metabolic rate. treating migraines. a group of therapeutic procedures that uses electronic or electromechanical instruments to measure. tightened muscles. one form of self-directed imagery that is based on the principle of mind-body connectivity 19.. chronic pain. and/or behavioral arousal 10. general sense of fear. used to visualize cancer cells being destroyed by cells of the immune system. irritability and negative mood 9. 8. and provide information to persons about their neuromuscular and ANS activity 21. b. decrease muscle tension. improve perceived well-being. teaches the individual how to effectively rest and reduce tension in the body 11. posture. process. contraindicated for people who have a strong fear of losing control or who are hypersensitive. hypertension. Goal of yoga is attainment of physical and mental well-being through mastery of body achieved through exercise. . nervousness. an affiliate of Elsevier Inc. proper breathing. and meditation. 2005 by Mosby. teaches the individual to relax individual muscle groups passively 12. visualization techniques that use the conscious mind to create mental images to stimulate physical changes in the body. Inc. the process whereby the practitioner becomes aware and fully present during the entire treatment b. improve well-being. Repressed emotions or feelings are sometimes uncovered. or alternating current or direct current fields. and/or enhance self-awareness 18. biofield: intended to affect energy fields that purportedly surround and penetrate the human body. 7. medication use 17. and achieve calmness and serenity 20.Study Guide Answer Key 88 j. a. is any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus 15. and a variety of gastrointestinal and urinary tract disorders 22. mild depression. and experiencing induced anxiety related to these feelings 14. holding of postures. such as pulsed fields. chronic fatigue syndrome. and consciousness. irritability. bioelectromagnetic-based therapies: involve the unconventional use of electromagnetic fields. lower heart rate and blood pressure. magnetic fields. feeling like they are floating. strokes. a. control or relieve pain. and reduce symptom distress 13. physiological. anxiety states. and the client has difficulty coping. 23. breathing mechanisms. chronic bereavement. involves the practitioner scanning the body of the client and diagnosing areas of accumulated tensions and redirecting these energies to bring the person back into balance 24. drug abuse.

attempting to rebalance the energy flow e. or treat and prevent disease 32. fractures. It is important for the nurse to know the current research being done in this area to provide accurate information not only to clients but also to other health care professionals. a pluralistic. increased Hb levels. . is consistent with the holistic approach nurses learn to practice 38. myofascial pain. an affiliate of Elsevier Inc. directs and balances the energy. 35. fainting. Mosby items and derived items © 2009. osteoarthritis. the perception that the treatments offered by the medical profession do not provide relief for a variety of common illnesses 39. depression. they can be sold as food or food supplements only. herbs. holes through which qi can be influenced by the insertion of needles e. antivirals 36. miscarriage. low back pain. bone and joint infections. multiple-practitioner treatment group. a. toxic agents. and arthritis 30. seizures. bleeding. diet. moxibustion. normalize physiological functions.Study Guide Answer Key 89 head to toes. and meditation 31. puncture of internal organ.. dislocations. spinal manipulation directed at certain joints. reduces anxiety levels. improves mood 26. comprises several modalities. noticing the quality of energy flow c. The goal is to restore balance within the individual by facilitating the person’s selfhealing ability. 2. vital energy of the body c. and musculoskeletal sprains 33. tennis elbow. a holistic therapy 28. sciatica. malignancy. complementary health care system. stimulating certain points on the body by the insertion of special needles to modify the perception of pain. shoulder pain. 40. Inc. therefore. contraindicated in persons who are sensitive to human interaction and touch and sensitivity to energy repatterning 27. broken needles. acupuncture. They have not received approval for use a drugs and are not regulated by the FDA. reduces headaches. 2005 by Mosby. a variety of standards utilized from one company to another 37. and post-treatment drowsiness 34. opposing yet complementary phenomena that exist in a state of dynamic equilibrium b. 2. facilitates the symmetrical and rhythmical flow of energy through the body d. channels of energy that run in regular patterns through the body and over its surface d. reassessment of the energy field 25. 3. treatment of liver and gallbladder conditions. restoring structural and functional imbalances 29. exercise. infections. whiplash. headaches. contamination with other chemicals or herbs.

n 5. posture appears less awkward. k 2. and muscles c. Inc. m 7. 25. Facing the direction of movement prevents abnormal twisting of the spine. 22. Mosby items and derived items © 2009. t 12. r 15.. c 20. The equilibrium of an object is maintained as long as the line of gravity passes through its base of support. o 10. j 19. a. 23. and the lumbar spinal curve appears. disorders of bones. joints. tremendous growth spurt in girls – hips widen. 31. curves in the cervical and lumbar vertebrae are accentuated. the greater the stability of the nurse. 24. 26. b 16. g 14. q 9. e 8. the greater the stability. an affiliate of Elsevier Inc. and foot eversion disappears. Leverage. Posture is awkward due to the slight swayback and protruding abdomen. congenital defects b. d 3. thighs and buttocks. s 11.Study Guide Answer Key Chapter 37: Activity and Exercise 90 1. rolling. 30. or pivoting requires less work than lifting. The wider the base of support. i 18. When friction is reduced between the object to be moved and the surface on which it is moved. Normal changes in posture and alignment occur in pregnant women. fat is deposited in upper arms. musculoskeletal trauma 29. central nervous system damage d. a 21. The lower the center of gravity. h 17. as growth and stability increase. Dividing balanced activity between arms and legs reduces the risk of back injury. which allows for sitting and standing. f 13. turning. . boys –long bone growth and increased muscle mass 32. 28. toward the end of toddlerhood. The infant’s spine is flexed and lacks the anteroposterior curves. less force is required to move it. 27. p 4. thoracic spine straightens. 2005 by Mosby. l 6.

manner or style of walking. spine is straight with normal curvatures. increases muscle strength and endurance. subtracting their current age from 220 and then obtain their target heart rate by taking 60% to 90% of the maximum 44. active –the client is able to move his or her joints independently. active ROM and stretching all muscle groups and joints c. a. 2005 by Mosby. cadence. the head is erect and midline. observing balance. the head is erect and the neck and vertebral column are in straight alignment. hormonal changes. jumping rope. blood pressure. expresses understanding of balancing rest and activity 43. maintaining fitness. and speed. head and neck should be aligned without excessive flexion or extension 37. . acute or chronic pain 42. a. a. bicycling. 41.. Mosby items and derived items © 2009. an affiliate of Elsevier Inc. includes weight training. limited movement. See Box 37-7 for answers. the thighs are parallel and in a horizontal plane. including rhythm. verbalizes an understanding of the need to gradually increase activity based on tolerance and symptoms c. posture. impaired physical mobility f. vertebrae are in straight alignment without observable curves. feet are flat on the floor 35. participates in prescribed physical activity while maintaining appropriate heart rate. aerobic dance. determine the degree of damage or injury to a joint. imbalanced nutrition g. risk for injury e. passive – the nurse moves each joint 47. abdomen is comfortably tucked. muscle groups used for walking should be exercised isometrically 4 times per day until the client is ambulatory 46. raking leaves. feet are supported on the floor 36. and ability to walk without assistance 39. and unequal movement 38. and breathing rate b. body parts are symmetrical. body weight is distributed on the buttocks and thighs.Study Guide Answer Key 91 33. pain. swelling. increases joint mobility 48. activity intolerance b. increased osteoclastic activity 34. ineffective coping c. improving health. knees are in a straight line between the hips and ankles and slightly flexed. impaired gas exchange d. Inc. shoveling snow. joint stiffness. activity for conditioning the body. or providing therapy for correcting a deformity or restoring the overall body to a maximal state of health 40. running. and cross-country skiing b. and kneading bread 45. walking. a progressive loss of total bone mass due to physical inactivity.

helping clients reach an optimal level of functioning 53. repeating the sequence c. pulse b. quad cane provides more support and is used for partial or complete leg paralysis or some hemiplegia 49.. each leg is moved alternatively with each opposing crutch so that three points are on the floor at all times b. improved quality of life.Study Guide Answer Key 92 a. reduced mortality and morbidity. decreased blood lipids. Mosby items and derived items © 2009. definition 56. 2005 by Mosby. psychological well-being 55. single straight-legged cane that is used to support and balance a client with decreased leg strength b. reduces systolic and diastolic blood pressure 52. Inc. it increases cardiac output 57. a. least partial weight bearing on each foot d. . 4. improved cardiovascular fitness and psychological well-being 54. weight is placed on supportive legs. increased functional capacity. an affiliate of Elsevier Inc. 2. bears weight on both crutches and then on the uninvolved leg. and increased psychological well-being 51. supporting the client’s weight 50. a. Refer to Figure 37-3 in the text for answers. strength d. crutches are one stride in front and then swings through with the crutches. blood pressure c. improved left ventricular function. endurance d.

mobility. poisonous gas 3. client’s home environment c. Environment: Includes all of the physical and psychosocial factors that influence the life and the survival of the client. Water pollution: Contamination of lakes. Bioterrorism: The use of anthrax. a. Relative humidity: Amount of water vapor in the air compared with the maximum amount of water vapor that the air could contain 7. In addition to being knowledgeable about the environment. an affiliate of Elsevier Inc. smallpox. Inc. health care environment Mosby items and derived items © 2009. Air pollution: Contamination of the atmosphere with a harmful chemical 9. List the four major risks to client safety in the health care environment a.Study Guide Answer Key 93 Chapter 38: Client Safety 1. Identify the specific client assessments to perform when considering possible threats to the client’s safety. sensory or communication impairment d. burns. electrical hazards) Safety and the Nursing Process Assessment 16. knowledge of common safety precautions 14. 2. and streams by industrial pollutants 11. processing. and distribution of foods. Noise pollution: Uncomfortable noise level 12. and botulism 13. Carbon monoxide: Colorless. and cosmetics 5. odorless.. rivers. lifestyle choices d. Land pollution: Caused by improper disposal of radioactive waste products 10. Hypothermia: Core temperature is 35ᵒ C or below 6. inflicted cuts) c. drugs. pneumonic plague. Food and Drug Administration (FDA): Federal agency responsible for regulating the manufacture. equipment-related accidents (rapid IV infusions. Food poisoning: Staphylococcal and clostridial bacteria are the most common types 4. . nursing history b. 2005 by Mosby. client-inherent accidents (seizures. sensory. falls b. client’s developmental level b. lack of sensory awareness 15. Immunization: Process by which resistance to an infectious disease is produced 8. Identify the individual risk factors that can pose a threat to safety: a. improper procedures) d. lifestyle b. and cognitive status c. procedure-related accidents (medication administrations. nurses must be familiar with: a. impaired mobility c.

disturbed thought processes 33. Identify general preventive measures to ensure a safer environment. risk for injury 28. risk for trauma Planning 34. clusters of clients arriving from a single locale 22. an affiliate of Elsevier Inc.. respiratory. risk for imbalanced body temperature 26. an unusual increase in the number of people seeking care with fever. 25. disturbed sensory/perception 31.Study Guide Answer Key d. risk for falls e. modifiable hazards will be reduced in the home environment by 100% within 1 month b. Inc. a. large number of rapidly fatal cases 23. temperature. or in an unusual pattern 20. client does not suffer a fall or injury c. Meet the basic needs related to oxygen. atypical clinical presentation Nursing Diagnosis Identify actual or potential nursing diagnoses that apply to clients whose safety is threatened. impaired home maintenance 27. any client presenting with a disease that is relatively uncommon to the geographic area and has bioterrorism potential 24. lower attack rates among clients are primarily indoors. client identifies risks associated with visual impairment Implementation Health promotion 35. risk for poisoning 30. Identify the expected outcomes that focus on the client’s need for safety. risk for suffocation 32. risk for medical errors 94 Identify the features that should alert nurses to the possibility of a bioterrorism-related out-break. deficient knowledge 29. location. an endemic disease rapidly emerging at an uncharacteristic time. a rapidly increasing incidence of a disease in a normally healthy population 18. or GI symptoms 19. in areas with filtered or closed ventilation. nutrition. and humidity Mosby items and derived items © 2009. compared with people who had been outdoors 21. 2005 by Mosby. . 17.

c. f.Study Guide Answer Key 95 Acute Care 36. Explain why an ambularm is used: a device that signals when the leg is in a dependent position 40. reduce the risk of client injury from falls b. reduce the risk of injury to others by the client 39. 37. Lock beds and wheelchairs when transferring a client from a bed to a wheelchair or back to bed. h. Show the client how to use the call light at the bedside and in bathroom. and grooming areas. positioning for adequate ventilation and drainage or oral secretions. Leave one side rail up and one down on the side where the oriented and ambulatory client gets out of bed. Explain seizure precautions to take: are nursing interventions to protect clients from traumatic injury. bathrooms. Place disoriented clients in room near nurses’ station. and secure safety straps around the client on a stretcher. and providing privacy and support following the event Mosby items and derived items © 2009. Remove clutter from bedside tables. mechanical. hallways. prevent interruption of therapy c. prevent the confused or combative client from removing life support equipment d. List eight measures to prevent falls in the health care setting a. inhaled. Use of restraints must meet the following objectives a. and place within easy reach. A physical restraint is: is a human. d. . b. an affiliate of Elsevier Inc. Inc. e.. or absorbed by the body 42. Place side rails in the up position. and/or physical device that is used with or without the client’s permission to restrict his/her freedom of movement or normal access to a person’s body and is not a usual part of the treatment plan 38. Maintain close supervision of confused clients. Explain the mnemonic RACE to set priorities in case of fire: R – rescue and remove all clients in immediate danger A – activate the alarm C –confine the fire by closing doors and windows and turning off oxygen and electrical equipment E – extinguish the fire using an extinguisher 41. A poison is: is any substance that impairs health or destroys life when ingested. g. 2005 by Mosby. Place bedside tables and over-bed tables close to client.

steps taken to increase a hospital’s ability to manage effects of an attack 46. steps taken by the staff in the event of an attack 47. Ms. d. 51.. Inc. 4. bathtub lacks safety strips or grab bars. Ms. and optimum temperature and humidity. “I bump into things. and use shielding devices 44. Throw rugs are on floors. The related factor becomes the basis for the selection of nursing therapies. home cluttered with furniture and small objects. the nurse integrates knowledge from nursing and other scientific disciplines and previous experiences in caring for clients who had an injury or were at risk. process to determine hazard vulnerability for the hospital’s service area 45. increase the client’s risk for falls 50. Critical-thinking attitudes such as perseverance and creativity would be applicable in this case. including the need for oxygen. 3. . steps taken to restore essential services and resume normal agency operations 48. Use the RACE to set priorities in case of fire. 4. and I’m afraid I’m going to fall. physiological needs . an affiliate of Elsevier Inc. 2005 by Mosby. Ms. Mosby items and derived items © 2009. Cohen has trouble reading and seeing familiar objects at a distance while wearing current glasses. due to the physiological changes that occur during the aging process.Study Guide Answer Key 96 43. make the distance from the source as great as possible.” Cabinets in kitchen are disorganized and full of breakable items that could fall out. 52. Identify the measures with which the nurse must be familiar to reduce exposure to radiation: limit the time spent near the source. influence a person’s safety 49. bathroom lighting is poor (40-watt bulbs). Ms. 3. She frequently holds walls for support. Cohen’s left arm and leg are weaker than those on the right. The American Nurses Association (ANA) standards for nursing practice address the nurse’s responsibility in maintaining client safety. In the case of safety. a. b. uncoordinated gait. Cohen states. c. Cohen has kyphosis and has a hesitant. nutrition.

Acne: Wash hair and skin thoroughly each day with warm water and soap to remove oil. a. fold of skin at the nail groove b. (Cream forms protective barrier and helps maintain fluid within skin. Know which clients require assistance to turn and change positions. and temperature sensation. body image d. dry thoroughly and gently. turgor. which maintain the hygiene and comfort of oral tissues b. a. a.) Use cream such as Eucerin.Study Guide Answer Key Chapter 39: Hygiene 97 1. Contact dermatitis: Avoid causative agents (e. or local nerve damage are unable to sense an injury to the skin. Implement dietary restrictions. sensation c. d. cultural variables g. an affiliate of Elsevier Inc. Observe dressing or bandage for retained moisture because it increases risk of infection. protection b. outer layer b. 2005 by Mosby. a. assess the status of sensory nerve function by checking for pain. lymph. health beliefs and motivation f. with loss of subcutaneous tissue. contains blood vessels. chewing c. During a bath. crescent-shaped white area 4. temperature regulation d. less elastic skin. Immobilization: When restricted from moving freely. circulatory insufficiency. temperature. Skin rashes: Wash area thoroughly and apply antiseptic spray or lotion to prevent further itching and aid in healing process. Wash abrasions with mild soap and water. Apply warm or cold soaks to relieve inflammation. Reduced sensation: Clients with paralysis. (Eliminate foods that aggravate condition from diet. thicker layer containing bundles of collagen and elastic fibers c. gum inflammation 5. physical condition 6. a. Abrasion: Be careful not to scratch client with jewelry or fingernails. Mosby items and derived items © 2009. 8. socioeconomic status e.g. Dry skin: Bathe less frequently and rinse body of all soap because residue left on skin can cause irritation and breakdown. the color. a. Use cosmetics sparingly because oily cosmetics or creams accumulate in pores and tend to make condition worse. c. social practices b. thickness. a. e. c. if necessary... excretion and secretion 3. personal preferences c. Nutrition and hydration: Clients with limited caloric and protein intake develop thinner. cleansers and soaps). Use creams to clean skin that is dry or allergic to soaps and detergents. b. Increase fluid intake when skin is dry. nerves. Add moisture to air through use of humidifier. reducing circulation to affected body parts.) Use prescribed topical antibiotics for severe forms of acne. and hydration 7. Inc. texture. and loose connective tissue with fat cells 2. if indicated. dependent body parts are exposed to pressure. b. This results in impaired or delayed wound healing. found in the mucosa lining the cheeks and mouth. tactile sensation. Use moisturizing cream to aid healing. .

Presence of perspiration. f. Foot odors: Foot odors are the result of excess perspiration promoting microorganism growth. Assess all surfaces exposed to casts. 9. Secretions and excretions: Moisture on the skin’s surface serves as a medium for bacterial growth and causes irritation. and raised. Pediculosis capitis: Parasite is on scalp attached to hair strands. f. tubing. grayish-white parasite insects infest mammals. a. Bites or pustules may be observed behind ears and at hairline. Small blisters containing fluid appear. Inc. In severe cases. . cloth restraints. c.. watery fecal material. a. oxygen. e. 2005 by Mosby. Body lice suck blood and lay eggs on clothing and furniture. e. Plantar warts: Fungating lesion appears on sole of foot and is caused by the papilloma virus. Inadequate blood flow causes ischemia and breakdown. Pediculosis corporis: Parasites tend to cling to clothing. Risk of infection also exists because delivery of nutrients. External devices: An external device applied to or around the skin exerts pressure or friction on the skin. Eggs look like oval particles. Corns: Friction and pressure from ill-fitting or loose shoes cause keratosis. Tinea pedis: Athlete’s foot is fungal infection of foot. Ingrown nails: Toenail or fingernail grows inward into soft tissue around nail. dandruff is on eyebrows. and wound drainage on the skin results in breakdown and infection. Corns are seen mainly on or between toes. scaliness and cracking of skin occurs between toes and on soles of feet. Corns are usually coneshaped. Crab lice are grayish white with red legs. Ingrown nail often results from improper nail trimming. Mosby items and derived items © 2009. urine. Dandruff: Scaling of scalp is accompanied by itching. b. c. d. gray-brown parasites burrow into skin and suck blood. and found on undersurface of foot or on palm of hand. Ticks: Small. keratotic cells. Vascular insufficiency: Inadequate arterial supply to tissues and impaired venous return decrease circulation to the extremities. and white blood cells to injured tissues is inadequate. f. d. similar to dandruff. Hair becomes brittle and broken. Pediculosis: Tiny. Pediculosis pubis: Parasites are in pubic hair. so they are not always easy to see. over bony prominences. g. Balding patches are in periphery of hair line. Soft corns are macerated. painless. an affiliate of Elsevier Inc. or orthopedic braces. Callus is usually flat. round. 10. bad breath 11. Alopecia: Alopecia occurs in all races.Study Guide Answer Key 98 d. softens epidermal cells. b. and leads to skin maceration. bandages and dressings. Calluses: Thickened portion of epidermis consists of mass of horny. e.

client’s skin is clean. Partial bath also includes washing back and providing back rub. impaired oral mucous membrane 18. bandage. Vascular insufficiency c. partial bed bath: Bed bath that consists of bathing only body parts that would cause discomfort if left unbathed. range of joint motion remains within normal limits on both affected and unaffected side 24. Limited protein or caloric intake and reduced hydration (e. and chewable vitamins over-the-counter (OTC). sponge bath: Involves bathing from a bath basin or sink with the client sitting in a chair. Lozenges. Eye care problems: Reduced dexterity and hand coordination 13. a. and health beliefs b. Client may still require the nurse’s assistance. Reduced sensation due to stroke. face. reinforce infection-control practices 25. a. weakness. Radiation therapy to head and neck. impaired dentition 17. local nerve damage. risk for impaired skin integrity 22.. a. trauma to mouth. Diabetes mellitus b. gastrointestinal alterations. dressing). a. tub bath: Involves immersion in a tub of water that allows more thorough washing and rinsing than a bed bath. Oral surgery.. Immunosuppression.Study Guide Answer Key 99 12. antacids. .. casts. complete bed bath: Bath administered to totally dependent client in bed (Skill 39-1) b. teach the client steps to avoid injury d. Mosby items and derived items © 2009. altered blood clotting. adapt instruction of any techniques to the client’s personal bathing facilities c. Chemotherapeutic drugs. fever. and intact without signs of inflammation b. Some institutions have tubs equipped with lifting devices that facilitate positioning dependent clients in the tub. spinal cord injury. placement of oral airway. Skin problems: Immobilization. axillae. motivations. poorly fitting dentures).g. Client is able to perform a portion of the bath independently. mouth breathers. dry. and wound drainage. such as the hands. fatigue 16. burns.g. Foot problems: Client unable to bend over or has reduced visual acuity d. Inc. Oral problems: Clients who are unable to use upper extremities due to paralysis. deficient knowledge about hygiene practices 15. Presence of nasogastric or oxygen tubes. Dehydration. urine.g. Dependent clients in need of partial hygiene or self-sufficient bedridden clients who are unable to reach all body parts receive a partial bath. ineffective health maintenance 20. c.reach areas. 2005 by Mosby. skin remains elastic and well-hydrated c. d.. risk for infection 23. chronic low self-esteem 14. diabetes. or restriction (e. an affiliate of Elsevier Inc. watery fecal material. ineffective tissue perfusion 21. make all instructions relevant after assessing knowledge. restraints. Assistance is needed for hard-to. impaired physical mobility 19. and perineal area. cough drops. Excessive secretions or excretions on the skin from perspiration. Presence of external devices (e. inability to take fluids or food by mouth (NPO). cast or dressing).

38. place directly over the eye. They require daily grooming due to food particles and mucus that collect on the hair. promote independence e. in a labeled container filled with tap water or saline 52. helps to keep hair clean and distributes oil evenly along hair shafts. easy to adjust c. 31. prevents hair from tangling 46. the Bag Bath contains several soft. Wear properly fitted shoes. 43. Instruct client to wash feet daily in lukewarm water and dry thoroughly. relieves muscular tension. 26. and decreases perception of pain 29. warm normal saline c. baby oil to dry areas of feet 35. 42. Inspect the feet daily. gently pull the skin taut and use short. The Bed Bath offers an alternative because of the ease of use. greatest risk are those males who are uncircumcised. dry socks 34. which will wash away the loosened wax. 48. consult with physician 37. clients who have indwelling catheters. 30. and client comfort. 39. foot examination yearly 32. need to be cleaned on a regular basis to avoid gingival infection and irritation 45.Study Guide Answer Key 100 e. frequency depends on a person’s daily routines and the condition of the hair 47. or clients recovering from rectal or genital surgery or childbirth 28. Do not wear new shoes for an extended time. a. a. . wash with a clean washcloth moistened in water. bed bath/travel bath: Developed by Skewes (1994). nonwoven cotton cloths that are premoisted in a solution of no-rinse surfactant cleanser and emollient. it does not accommodate progressive hearing loss and requires manual dexterity to operate b. 49. powerful. squeezing lifts the eye from the socket b. reduced bathing time. provide privacy b. Shave facial hair after the bath or shampoo. promotes relaxation. file the toenails straight across and square 36. Thorough tooth brushing at least 4 times a day is basic. Exercise regularly to improve circulation. anticipate needs 27. retract the upper and lower lids and gently slip the eye into the socket d. 41. firm razor strokes in the direction the hair grows. 50. use a small. 40. do not use OTCs to treat foot conditions. obtain new brushes every 3 months. then instill 250 cc of warm water into the ear.. maintain warmth d. extended wear. it requires adequate ear diameter and depth for proper fit. a. fits into the external ear and allows for more fine tuning. clean. apply lanolin. an affiliate of Elsevier Inc. hooks around Mosby items and derived items © 2009. Inc. Unconscious clients will require more frequent eye care. Instill 3 drops of glycerin at bedtime to soften the wax and 3 drops of hydrogen peroxide twice a day to loosen the wax. removes plaque and tartar between teeth 44. to avoid causing discomfort. unscented foot powder for perspiration 33. 2005 by Mosby. rubber bulb syringe to create a suction effect. 53. and disposable 51. Wash minor cuts immediately and dry thoroughly. daily wear. maintain safety c. using a mirror. Avoid wearing elastic stockings.

Wyatt in the plan by asking her what is important to her to gain from her visit. Mrs. useful for clients with progressive hearing loss 54. “it hurts to move my arms above my head. Wyatt lives in a first-floor apartment in a retirement center. Wyatt’s hair is not washed or combed. which determines client’s ability to perform self-care and level of assistance required from nurse. Mrs.” Mrs. She states. Jeannette’s assessment reveals defining characteristics of an inability to wash body parts. a daughter. which is easily able to spread to furniture and other people if not treated. She wants to continue to be independent in making decisions about her care. She tells Jeannette. She involves Mrs. Each client has individual desires and preferences about when to bathe. and shower seat is available. shave. The nurse.” Jeannette assesses the client’s tolerance for activity. consult a podiatrist as needed. an affiliate of Elsevier Inc. weakness. a bath that is administered to totally dependent client in bed 56. The floor in the shower is slippery. 58. type of hygiene products. Her shoes are worn and illfitting. difficulty turning and regulating a water faucet. the skin becomes very dry and flaky. 2. with frequent bathing or exposure to low humidity. and mobility limitations in the dominant hand. Wyatt. Wyatt is a widow with her only child. Current bathroom has a shower with handgrips. 2. 59. The condition of the skin depends on the exposure to environmental irritants. discomfort level. do not use scissors or clippers. a. The handles on the shower are levers versus faucets. Trendelenburg’s: Entire bed frame tilted with head of bed down d.” Jeannette also assesses the client’s bathing preferences: frequency and time of day. cognitive ability. Wyatt states. makes the initial home visit for Mrs. Jeannette synthesizes information that she has obtained from her assessment to develop a plan of care. Edith Wyatt is a 77-year-old female with a history of degenerative arthritis and diabetes mellitus for 3 years and complains of pain in the joints. 3.. unkempt appearance. 2. allows for fine tuning. Assess range of motion of upper extremities. Jeannette. foot of bed may also be raised at knee b. “I cannot get used to the new bathroom. File the toenails straight across and square. Mrs. . I cannot reach my towels and soap. 3. living in a city 200 miles away. The room also has a small closet for linens with a large counter top adjunct to sink. 57. Use a medicated shampoo for eliminating lice.Study Guide Answer Key 101 and behind the ear and is connected to an ear mold. Inc. and limited motion of arms. 60. Jeannette also observes Mrs. “It is important for me to be able to care for myself. She moved in three weeks earlier. levers turn up and down versus clockwise. Flat: Entire bed frame horizontally parallel with floor 55. and musculoskeletal function. Jeannette asked Mosby items and derived items © 2009. Semi-Fowler’s: Head of bed raised approximately 30 degrees. foot of bed may also be raised at knee c. Fowler’s: Head of bed raised to angle of 45 degrees or more. Wyatt to have a right limp. and perform hair care. Reverse Trendlenburg’s: Entire bed frame tilted with foot of bed down e. inclination less than Fowler’s position. I have not been to the hair dresser since I arrived here. Mrs. 2005 by Mosby. semi-sitting position.

Wyatt how long she has limped and if she has any pain. “I have my doctor trim my toenails every month.” Jeannette involved Mrs.. The outer aspect of the little toe on right foot is reddened. Mosby items and derived items © 2009. Wyatt when making decisions regarding her care. Both feet are dry and toenails evenly trimmed at end of toe.” Jeannette assesses the condition of Mrs. Mrs. an affiliate of Elsevier Inc. 2005 by Mosby. She became creative in adapting an approach to her self-care by setting up an appointment with a home health-care agency to provide a home-care assistant to assist Mrs. especially by the little toe.Study Guide Answer Key 102 Mrs. . tender to touch with intact skin. Wyatt replies “My right foot hurts. Wyatt with her bathing and hair care. Wyatt states that she has a monthly appointment scheduled for the next 6 months for toenail trimming and care. Mrs. Wyatt’s feet and her knowledge about prevention and routine foot care. Wyatt states. This has been going on for about two weeks. because of my sugar problems. Mrs. Inc.

b 6. a.12-0. e 3. conduction thru both atria 10. h 4.. incisions) e. trauma. an affiliate of Elsevier Inc. c 23. impulse travel time through the AV node (. alterations that affect the oxygen-carrying capacity (anemia) c. neuromuscular diseases (decrease the ability to expand and contract the chest wall) f. rate greater than 100 b. chronic diseases (chronic hypoxemia) 25. decreased inspired oxygen concentration (high altitudes. cardiomyopathic conditions. d 19. infection) 24. . Regular rhythm. myocardial hypoxia.012 -. Inc. hypoxia) b. a. CNS) d. 2005 by Mosby.12 seconds) 12.20 seconds) 11. time needed for ventricular depolarization and repolarization (0. hypoventilation. d 9. pregnancy (inspiratory capacity declines) b. hypovolemia (shock and severe dehydration) e. b 21. the impulse traveled through the ventricles (0. muscular disease. increased metabolic rate (pregnancy. cardiac disorders: disturbances in conduction. drug overdoses) d. trauma (flail chest. c 2. rate less than 60 c. musculoskeletal abnormalities (structural configurations. Electrical impulse in the atria is chaotic and originates from multiple sites Mosby items and derived items © 2009. f 20.06 – 0. impaired valvular function. a 8. h 18.Study Guide Answer Key Chapter 40: Oxygenation 103 1. fever.42 seconds) 13. and peripheral tissue hypoxia Respiratory disorders (hyperventilation. g 7. j 17. a. CNS (reduced inspiratory lung volumes) g. e 14. a 22. g 15. i 16. Regular rhythm. f 5. obesity (reduced lung volumes) c.

cardiac risk factors b. Uncoordinated electrical activity. illegal substances. airborne fibers 43. moderate exercise 42. alveolar ventilation is inadequate to meet the body’s oxygen demand 34. chest trauma) 36. breathlessness. QRS complex is usually widened and bizarre e. transient imbalance between myocardial oxygen supply and demand 30. impaired functioning on the right ventricle (weight gain. environmental exposure. or infection) 32. smoking use Mosby items and derived items © 2009. QRS. inflammation. smoking 40. lack of exercise. includes unstable angina. 2005 by Mosby. wheezing. impulse originates in ventricles. weight reduction c. peripheral circulation. MI (nonocclusive thrombus. a. atherosclerosis. or T wave 26. SOB. collapse of the alveoli which prevents normal exchange of oxygen and carbon dioxide 35. hepatomegaly and splenomegaly. Inc. talcum powder c. high altitudes. excess ventilation required to eliminate the carbon dioxide produced (anxiety. a. infections. pain. secondhand smoke. an affiliate of Elsevier Inc. osteoporosis 41. a. back flow of blood into an adjacent chamber 28. OTCs. dizziness. frequency of infections. pneumonia. distended neck veins. smoking cessation b. risk factors. blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries 37. asbestos b. cardiac function – pain. decreased functioning of the left ventricle (fatigue. dyspnea. drugs. flow of blood through the valve is obstructed b. exposure to respiratory infections. and smoking 39. low-cholesterol and low-sodium diet d. stress. Life threatening. medication use. and confusion) b. and dependent peripheral edema) 27.Study Guide Answer Key 104 d. poisoning. and ST-segment elevation. results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet the myocardial oxygen demand 29. or an acid-base imbalance) 33. results from a sudden decrease in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion 31. fatigue.. upper respiratory tract infections due to frequent exposures and secondhand smoke 38. . a. inadequate tissue oxygenation at the cellular level (decreased hemoglobin levels. shock. dust d. respiratory function – cough. unhealthy diet. coronary vasospasm. non-ST segment elevation MI. a. management of hypertension e. no identifiable P. aging changes.

Provides more specific information about difficult-to-treat dysrhythmias. areas of tenderness. level of consciousness. b. f. Graphically demonstrates overall cardiac performance. Electrophysiological studies (EPS): Invasive measure of intracardiac electrical pathways. the great vessels. is a subjective sensation (loss of endurance) 46. a protective reflex to clear the trachea. Exercise stress test: ECG is monitored while the client walks on a treadmill at a specified speed and duration of time. identify normal and abnormal heart and lung sounds 54. heaves. d. valves. Determines coronary blood flow changes with increased activity. identifies tactile fremitus. Mosby items and derived items © 2009. c. The test is not a valuable tool for evaluation of cardiac response in women due to an increased false-positive finding.Study Guide Answer Key 105 44. systemic circulation. a. detects the presence of abnormal fluid or air in the lungs 53. myocardial perfusion. Used to evaluate the cardiac response to physical stress. usually associated with exercise or excitement associated with many medical and environmental factors 47. clinical sign of hypoxia. trauma. Inc. and PMI 52. Used to differentiate pulmonary obstructive disease from restrictive disease. e. breathing patterns. is peripheral and radiates to the scapular regions c. g. and chest wall movement 51. Evaluation of the ECG recording along with the diary provides information about the heart’s electrical activity during activities of daily living. Used to evaluate cardiac structure. audible expulsion of air from the lungs. thrills. noting when they experience rapid heartbeats or dizziness. 55. Holter monitor: Portable ECG worn by the client. a. sudden. an affiliate of Elsevier Inc. The test produces a continuous ECG tracing over a period of time. Echocardiography: Noninvasive measure of heart structure and heart wall motion. often present following exercise. prolonged coughing episodes 45. Scintigraphy: Radionuclide angiography. a. abnormal condition in which the client uses multiple pillows when lying down 48. Thallium stress test: An ECG stress test with the addition of thallium-201 injected IV.. does not occur with respiratory variations b. and lungs of irritants and secretions 49. and contractility. high-pitched musical sound caused by high-velocity movement of air through a narrowed airway 50. type of thoracic excursion. 2005 by Mosby. . Cardiac catheterization and angiography: Used to visualize cardiac chambers. Assesses adequacy of antidysrhythmic medication. general appearance. and coronary arteries. bronchi. Clients keep a diary of activity. Pressures and volumes within the four chambers of the heart are also measured. observe the client for skin and mucous membrane color. Pulmonary function tests: Determine the ability of the lungs to efficiently exchange oxygen and carbon dioxide.

anxiety 58. Bronchoscopy: Visual examination of the tracheobronchial tree through a narrow. Daily measurement is for early detection of asthma exacerbations. 2005 by Mosby. flexible fiberoptic bronchoscope. ineffective airway clearance 64. e. Peak expiratory flow rate (PEFR): The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. coughs productively d. risk for infection 68. chest physiotherapy d. achieves maintenance and promotion of bilateral lung expansion c. artificial airway 72. a. remove mucous plugs or foreign bodies. biofeedback f. an affiliate of Elsevier Inc. postural drainage 71. The results may indicate an infection or neoplastic disease. or biopsy samples. Inc. exercise b. . fatigue 60. breathing techniques c. a. impaired spontaneous ventilation 62.Study Guide Answer Key 106 b. relaxation techniques e. Thoracentesis: Specimen of pleural fluid is obtained for cytological examination. Performed to obtain fluid. nebulization c. activity intolerance 57. sputum. lungs are clear to auscultation b. decreased cardiac output 59. d. c. oropharyngeal and nasopharyngeal b.. ineffective breathing pattern 65. impaired verbal communication 63. a. frequent changes of position are effective for reducing stasis of pulmonary secretions and decreased chest wall expansion (Semi-Fowler’s is the most effective position) Mosby items and derived items © 2009. Identification of infection or a type of cancer is important in determining a plan of care. orotracheal and nasotracheal c. Identification of masses is used in planning therapy and treatments. risk for imbalanced fluid volume 67. pulse oximetry is maintained or improved 69. cough control d. 56. a. impaired gas exchange 61. humidification b. Lung scan: Used to identify abnormal masses by size and location. ineffective health maintenance 66. meditation 70.

causes skin irritation or breakdown. comfortable device used for oxygen delivery (Skill 40-4). delivers humidity with oxygen concentration. Disadvantages include: unable to use with nasal obstruction. compliance 81. caused by loss of negative intrapleural pressure 76. an affiliate of Elsevier Inc. or heated humidity. 78. protrude from the center of a disposable tube and are inserted into the nares (Figure 40-13). to reestablish normal intrapleural and intrapulmonic pressures 75. to prevent air or fluid from reentering the pleural space c. does not impede eating or talking. nutrition counseling c. a PaO2 of 55 mm Hg or less or an SaO2 of 88% or less on room air at rest. Advantages include: safe and simple.5 cm (½ inch) long. does not dry mucous membranes. Disadvantages include: exact FIO2 level is difficult to estimate. It fits snugly over the mouth and nose and is secured in place with a strap and it assists in providing humidified oxygen.Study Guide Answer Key 107 73. requires high FIO2 levels to prevent re-breathing of carbon dioxide. involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse Mosby items and derived items © 2009. a. Advantages include: controls the amount of specified oxygen concentration. a. easily tolerated. client inhales room air through the side holes in the mask. and drink. delivers low concentrations while allowing the client to eat. is to prevent or relieve hypoxia 77. Delivers percentage of FIO2 from 24-60%. Nasal cannula: A nasal cannula is a simple. b. Face mask: An oxygen face mask is a device used to administer oxygen. a. encourages voluntary deep breathing and prevents atelectasis by using visual feedback 74. physical exercise b. depending on the flow-control meter selected. about 1. on exertion. speak. relaxation and stress management techniques d. 2005 by Mosby. cascade cough – promotes airway clearance and patent airway in clients with large volumes of sputum. The two cannulas. client’s breathing pattern will affect exact FIO2. prescribed medications and oxygen e. Huff cough – stimulates a natural cough reflex and is effective only for clearing central airways 82. . improves muscle strength and endurance 83. c. to remove air and fluids from the pleural space b. Inc. collection of air in the pleural space. can dislodge easily. accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae usually due to trauma b. humidity. is inexpensive and disposable. Venturi mask: The Venturi mask delivers oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min. a.. drying to mucous membranes. A-airway B-breathing C-circulation 80. or with exercise 79.

2. does not exercise. PFTs c. 88.Study Guide Answer Key 108 84. and vibration. an affiliate of Elsevier Inc.4. 88. Interventions based upon the data would include increasing fluids to 1000 mL in 24 hours to liquefy secretions. The heart must work to overcome this resistance to fully eject blood from the left ventricle.. 130/90. 2005 by Mosby. These are the 3 steps in the process of oxygenation. 1. Inc. 91. His SpO2 ranges from 78-84%. 90. Edwards’ statement indicates that he has a cough. 87. and his vital signs are 100. have Mr. 89. VS d. Help identify community resources and support systems for both the client and family in preventing and managing symptoms related to his COPD upon discharge from the hospital. Mosby items and derived items © 2009. he has abnormal breath sounds in the lower lobes and has a productive cough of thick and discolored yellow-to-yellow green sputum. . Gases move into and out of the lungs through pressure changes (intrapleural and atmospheric). ECG e. Mr. 3. Edwards’ skin and mucus membranes are dry. Mr. Edwards deepbreathe and cough every 2 hours 4 to 5 times. All other answers are related to the subjective sensation of dyspnea. and continues to smoke ½ pack of cigarettes a day. is fatigued. 1. Initiate chest physiotherapy (CPT) if there is evidence of infiltrates on chest X-ray. a. physical assessment data 86. evaluation of ABGs b. improves efficiency of breathing by decreasing air trapping and reducing the work of breathing 85. percussion. CPT includes postural drainage. and teach Mr. 2. Edwards effective cough techniques to clear secretions. 26 SpO2 87%.

at risk are clients who are unable to perceive or respond to the thirst mechanism 22. random movement of a solute in a solution across a semipermeable membrane from an area of higher concentration to an area of lower concentration 15. in response to fluid pressure. causes vasoconstriction b. causing them to shrink) 13. continually monitor the serum osmotic pressure 20. . the difference between 2 concentrations 16. 8. causing them to enlarge) 14. positively charged electrolytes (sodium. a solution of higher osmotic pressure (pulls fluid from cells. or both. excess fluid is lost 21. plays a critical role in the balance of fluid and electrolytes and the maintenance of vascular tone 25. Inc. a solution of lower osmotic pressure (moves fluids into the cells. involves the movement of a pure solvent across a semipermeable membrane from an area of lesser solute concentration to an area of greater solute concentration 7. is continuous and occurs through the skin and lungs. relocates blood flow to kidneys and stimulates the release of aldosterone (when the sodium is low) c. carbon dioxide. lungs. skin. fluid intake b. The concentration of a solution is measured. is the fluid outside the cell (interstitial. is the drawing power of water and depends on the number of molecules in solution 9. kidneys. ions. intravascular. a. oxygen. glucose. Electrolyte. Mosby items and derived items © 2009. a. and calcium) 3. represents the number of grams of the specific electrolyte dissolved in a liter of plasma 5. the osmotic pressure of a solution 10. comprises all fluid within the cells of the body (42% of body weight) b. bicarbonate. gastrointestinal tract 26. ADH – is stored in the pituitary gland and is released in response to changes in the blood osmolarity 23. massive selective vasoconstriction of blood vessels.. moving from an area of higher pressure to one of lower pressure 17. are electrolytes. a. occurs through excess perspiration and can be perceived by the client 27. and transcellular fluid) 2. and Acid-Base Balance 109 1. an affiliate of Elsevier Inc. another term that describes the concentration of solution 11. and sulfate) 4. adrenal cortex releases in response to increased plasma potassium levels 24. the solutions on both sides of the semipermeable membrane are equal in concentration (expand the body’s fluid volume without causing a fluid shift from one compartment to another) 12. requires metabolic activity and expenditure of energy to move substances across the cell membrane 18. potassium. negatively charged electrolytes (chloride. fluid output 19. is the process by which water and diffusible substances move together across a membrane. which reflects the amount of a substance in the form of molecules. and proteins 6. 2005 by Mosby. hormonal controls c. a. not perceived by the person b.Study Guide Answer Key Chapter 41: Fluid.

5 mg/dl Absorbed from intestine. Phosphate also promotes normal neuromuscular action and participates in carbohydrate metabolism. and actions of the parathyroid hormone (PTH). renal mechanisms. and skeletal and smooth muscle contraction Bone and teeth formation. It is regulated by dietary intake. cardiac conduction. blood clotting. cell membrane integrity.Study Guide Answer Key 110 Electrolyte Values Sodium 135-145 mEq/L Potassium 3. a. Serum chloride is regulated by dietary intake and the kidneys. Phosphate and calcium help to develop and maintain bones and teeth. Phosphate is normally absorbed through the GI tract. Regulated by parathyroid hormone. and PTH.. transmission and conduction of nerve impulses. Inc. vitamin D & calcitonin. hormone secretion.5 mEq/L Chloride 95-105 mEq/L Bicarbonate 22-26 (arterial) mEq/L 24-30 (venous) mEq/L Phosphate 2. . chemical b. and muscle contraction Essential for enzyme activities. Magnesium 1.0 mEq/L Calcium 4. Regulatory Mechanism Dietary intake and aldosterone secretion Dietary intake and renal excretion regulate potassium.8-4. 2005 by Mosby. an affiliate of Elsevier Inc. neurochemical activities. The transport of chloride follows sodium. biological c. intestinal absorption. Serum magnesium is regulated by dietary intake.5-5. and cardiac and skeletal muscle excitability Chloride is the major anion in ECF. transmission of nerve impulses. normal cardiac conduction. renal excretion. physiological buffering Mosby items and derived items © 2009. The bicarbonate ion is an essential component of the carbonic acid-bicarbonate buffering system essential to acid-base balance. excreted by the kidneys and resorption or deposition in bone.5 mg/dl Function Major contributor to maintaining water balance Is necessary for glycogen deposits in the liver and skeletal muscle. It assists in acid-base regulation. 28.5-5.5-2. The kidneys regulate bicarbonate.

ventricular and weak. and cardiac arrest occurs serum ionized calcium level numbness and tingling of below 4. tendon reflexes. . irregular pulse dysrhythmias) serum potassium level above anxiety. nausea and vomiting. ST segment sounds. convulsions.5 mEq/L and muscle weakness. dysrhythmias. dry mucous membranes. postural hypotension. weakness. Imbalance Hyponatremia Lab Finding serum sodium level below 135 mEq/L. Inc. serum osmolality 280 mOsm/kg. ventricular potentiated digoxin effects dysrhythmias. heart block. nausea electrocardiogram (ECG) and vomiting. mg/dl and ECG hyperactive reflexes.5 mEq/L or total fingers and circumoral serum calcium below 8. and coma serum sodium levels above extreme thirst. dry and sticky 300 mOsm/kg. convulsions.5 (around mouth) region. positive Chvostek’s sign (contraction of facial muscles when facial Hypernatremia Hypokalemia Hyperkalemia Hypocalcemia Mosby items and derived items © 2009. eventually QRS pattern widens.. decreased deep depression.030 (if not membranes. (e.010 (if not caused by SIADH) Signs and Symptoms apprehension. abnormalities: peaked T abdominal cramps. an affiliate of Elsevier Inc. 3. and urine specific gravity below 1. postural dizziness.Study Guide Answer Key 111 29.0 mEq/L and ECG paresthesia. 2005 by Mosby. agitation. postural caused by diabetes insipidus) hypotension. personality change.. dry and 145 mEq/L. serum osmolality flushed skin. and urine tongue and mucous specific gravity 1. 5. abdominal cramping. and wave and widened QRS diarrhea complex (bradycardia. decreased bowel wave. tachycardia. dysrhythmias). diarrhea. fever. u wave. paresthesias. abnormalities: ventricular positive Trousseau’s sign tachycardia (carpopedal spasm with hypoxia).g. intestinal abnormalities: flattened T distention. and irritability serum potassium level below weakness and fatigue. restlessness.

Inc.5 mEq/L.5 mEq/L Hypermagnesemia serum magnesium level above 2.5 mg/100 ml caused by fluid volume deficit (FVD) or renal damage caused by urolithiasis.5 mg/dl. hypertension. is the amount of blood buffer (hemoglobin and bicarbonate) that exists (+/. hyperactive deep tendon reflexes.. . ECG abnormalities: heart block serum magnesium level below 1. decreased level of consciousness. confusion and disorientation. lethargy. and flushing 30. hypoactive reflexes. an affiliate of Elsevier Inc. ECG abnormalities: prolonged QT interval. 2005 by Mosby.35-7. flank pain (from kidney stones). is the partial pressure carbon dioxide in arterial blood (35-45) c.2) f. and pathological fractures (chronic hypocalcemia) anorexia. muscle cramps. hypotension. weakness. tetany. is the partial pressure of oxygen in the blood (80-100) d.Study Guide Answer Key 112 nerve is tapped). tachycardia. nausea and vomiting. a. AV block muscular tremors. dysrhythmias. and cardiac arrest Hypercalcemia Hypomagnesemia serum ionized calcium level above 5. is the point at which hemoglobin is saturated by oxygen (95-99% ) e. measures the hydrogen ion concentration in the body fluids (7. and elevated blood urea nitrogen (BUN) level 25 mg/100 ml and elevated creatinine level 1. widespread bone cavitation. and positive Chvostek’s sign and Trousseau’s sign acute elevations in magnesium levels: hypoactive deep tendon reflexes. personality changes.5 mEq/L or total serum calcium level above 10. x-ray examination showing generalized osteoporosis. is the major renal component of acid-base balance (22-26) Mosby items and derived items © 2009. radiopaque urinary stones.45) b. decreased depth and rate of respirations.

. Infants and children have greater water needs and are more vulnerable to fluid volume alterations. head injuries. adolescents have increased metabolic processes. and bicarbonate level normal (if uncompensated) or > 26 mEq/L (if compensated) arterial blood gas alterations: pH > 7. PaCO2 < 35 mm Hg. b. Inc. very old Gender – Women Environment – Diet. and circumoral region. Acid-Base Imbalance Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Lab Findings arterial blood gas alterations: pH < 7. tachypnea.35. and coma dizziness. confusion. numbness and tingling of extremities. headache. tetany 32. Therapies – Diuretics. endocrine diseases such as Cushing’s disease and diabetes mellitus. an affiliate of Elsevier Inc.35. Mosby items and derived items © 2009. and coma headache. cardiovascular disease. c. a. bicarbonate level < 22 mEq/L. dysrhythmias. tachypnea with deep respirations. . such as congestive heart failure. deep respirations). convulsions. fever in children creates an increase in the rate of insensible water loss. PaO2 < 80 mm Hg. convulsions. PaCO2 normal (if uncompensated) or > 45 mm Hg (if compensated).45. muscular twitching. warm and flushed skin. dysrhythmias. exercise. toes. abdominal cramps. intravenous (IV) therapy. and flushed skin Dizziness.45. malnutrition. lethargy. ventricular dysrhythmias. and renal disease e. muscle cramps.Study Guide Answer Key 113 31. older adults have decreased thirst sensation that often causes electrolyte imbalances. steroids. and oxygen saturation normal arterial blood gas alterations: pH > 7. lethargy. and total parenteral nutrition (TPN) 33. Trauma – Crash injuries. and bicarbonate level normal (if short lived or uncompensated) or < 22 mEq/L (if compensated) arterial blood gas alterations: pH < 7. 2005 by Mosby. burns f. chronic obstructive pulmonary disease. confusion. and hot weather and sweating Chronic Diseases – Cancer. PaCO2 normal (if uncompensated) or < 35 mm Hg (if compensated). PaO2 normal or increased (with rapid. dizziness. numbness and tingling of fingers. and bicarbonate level > 26 mEq/L Signs and Symptoms confusion. PaO2 normal. d. dysrhythmias. PaCO2 > 45 mm Hg. PaO2 normal. Age – Very young.

the greater the body’s response. . carbenicillin. including intestinal and gastric ulcers and diarrhea Respiratory center depressants(e. can result in cerebral edema and diabetes insipidus 39. respiratory acidosis.g. vancomycin. and hypokalemia Steroids—metabolic alkalosis Potassium supplements—GI disturbances. opioid analgesics)— decreased rate and depth of respirations. Lethargy: FVD. Irritability: Metabolic or respiratory alkalosis.g. and second. hypoalbuminemia. hyperkalemia. hypercalcemia d. Chvostek’s sign: hypocalcemia g. resulting in respiratory acidosis Antibiotics—nephrotoxicity (e. Inc. Weight loss of 5% to 8%: Mild-to-moderate fluid volume deficit (FVD) b. potassium imbalance. hypomagnesemia i. hyperosmolar imbalance.. CHF. potassium and water (metabolic acidosis) 43. dry mucous membranes: FVD. vigorous exercise or exposure to extreme temperatures 45. causes an abnormal retention of sodium chloride. Distended neck veins: FVE h. metabolic acidosis or alkalosis. hypernatremia. Periorbital edema: FVE e. potassium.g. edema) 46. a. predispose to respiratory acidosis and/or respiratory alkalosis 38. an affiliate of Elsevier Inc. 37. hyperkalemia. hypokalemia c. The greater the body surface burned. and chloride ions 44. Diuretics—metabolic alkalosis. The more extensive the surgery and fluid loss. 36. piperacillin. Weak pulse: FVD.. diminished cardiac output. recent changes in appetite or the ability to chew and swallow (breakdown of glycogen and fat stores.Study Guide Answer Key 114 34. respiratory alkalosis and acidosis. or renal disease 40. cancer.and third-degree burns place the clients at risk. Dysrhythmias: Metabolic acidosis. gastroenteritis and nasogastric suctioning result in the loss of fluid. hyponatremia. history of smoking or alcohol consumption (respiratory acidosis) 47. depends on the type and progression of the cancer and its treatment (diarrhea and anorexia) 41. ticarcillin. aminoglycosides). Low blood pressure: FVD. which reduces kidney perfusion and decreases urine output 42. hypernatremia f. hypermagnesemia Mosby items and derived items © 2009. Surgery. azlocillin. 2005 by Mosby... metabolic acidosis. methicillin. unasyn) Calcium carbonate (Tums)— mild metabolic alkalosis with nausea and vomiting Magnesium hydroxide (Milk of Magnesia)—hypokalemia Nonsteroidal anti-inflammatory drugs—nephrotoxicity 48. hyperkalemia and/or hypernatremia (e. hypokalemia j. the greater the fluid loss. head and chest trauma. 35. Sticky. shock.

nutrients. impaired oral mucous membrane 57. hypomagnesemia. excess fluid volume 53. an affiliate of Elsevier Inc. hypercalcemia v. l. r. o. metabolic 115 Hypertonicity of muscles on palpation: Hypocalcemia. include TPN.Study Guide Answer Key k. crystalloids. . percutaneously or implanted or tunneled 64. ineffective tissue perfusion 59. and colloids 63. Distended abdomen: Third-space syndrome x. Decreased or absent deep tendon reflexes: Hypokalemia. FVE Increased specific gravity: FVD Muscle cramps. balanced I & O. may be appropriate when the client’s GI tract is healthy but the client cannot ingest fluids 61. 2 edema: FVE 49. alkalosis t. lactated Ringer’s Mosby items and derived items © 2009.. Inc. or infusion ports designed for repeated access to the vascular system. acidosis m. risk for injury 55. clammy skin: FVD y. Increased temperature: Hypernatremia. Isotonic: Dextrose 5% in water. a. 0. will be free of complications associated with the IV device throughout the duration of IV therapy b. acute confusion 51. will demonstrate fluid balance as evidenced by moist. and electrolytes administered peripherally. impaired skin integrity 58. deficient fluid volume 52. n. 2005 by Mosby. hyperosmolar imbalance. VADs are catheters. 66. is to correct or prevent fluid and electrolyte imbalances 65. Cold. clients who retain fluids and have fluid volume excess require restriction of fluids 62. cannulas. q. a. mucous membranes. tetany: Hypocalcemia. s. metabolic or respiratory Third heart sound: FVE Increased respiratory rate: FVE. will have serum electrolytes within the normal range within 48 hours 60. decreased cardiac output 50. Crackles: FVE Anorexia: Metabolic acidosis Abdominal cramps: Metabolic acidosis Poor skin turgor: FVD Oliguria or anuria: FVD.9% sodium chloride (normal saline). deficient knowledge regarding disease management 56. and stable weights within 48 hours c. p. respiratory alkalosis. impaired gas exchange 54. is a nutritionally adequate hypertonic solution consisting of glucose. metabolic acidosis w. metabolic alkalosis u.

Inc. dextrose 5% in lactated Ringer’s Mosby items and derived items © 2009. . 2005 by Mosby.45% sodium chloride (half normal saline).33% sodium chloride (one-third normal saline) c.9% sodium chloride. an affiliate of Elsevier Inc.. Hypertonic: Dextrose 10% in water. 0. 116 Hypotonic: 0. dextrose 5% in 0. 3%-5% sodium chloride.45% NaCl sodium chloride.Study Guide Answer Key b. dextrose 5% in 0.

Study Guide Answer Key 117 67. swollen Gross edema >6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate to severe pain Infiltration of any amount of blood product.. translucent Skin tight. < 1 inch in any direction Cool to touch With or without pain 2 Skin blanched Edema 1-6 inches in any direction Cool to touch With or without pain 3 Skin blanched. or vesicant Phlebitis Scale Grade Clinical Criteria 0 1 2 3 No symptoms Erythema at access site with or without pain Pain at access site with erythema and/or edema Pain at access site with erythema and/or edema Mosby items and derived items © 2009. . Infiltration Scale Grade Clinical Criteria 0 1 No symptoms Skin blanched Edema. translucent Gross edema >6 inches in any direction Cool to touch Mild to moderate pain Possible numbness 4 Skin blanched. Inc. 2005 by Mosby. an affiliate of Elsevier Inc. irritant. leaking Skin discolored. bruised.

begin transfusion slowly. causing RBC destruction Febrile. platelets. Inc. baseline vital signs f. .Study Guide Answer Key Streak formation Palpable venous cord 4 Pain at access site with erythema and/or edema Streak formation Palpable venous cord >1 inch in length Purulent drainage 118 68. or components containing 10 ml or more of RBCs Antibodies in the recipient’s plasma attach to antigens on transfused RBCs. hemoglobinemia. an 18-gauge or 19-gauge cannula b. tachypnea. tubing. which can be life threatening 76. and site dressings c. low back pain. a stylet covered with a plastic cannula (ONC). tachycardia. are necessary for administering small hourly volumes (<20 ml/hr) and for clients who are at risk for volume overloads 70. AB individual 75. in line filter tubing c. Reaction Cause Clinical Manifestations Acute hemolytic Infusion of ABO-incompatible whole blood. muscle pain Flushing. or a needle attached to a syringe 69. increase circulating blood volume after surgery. AB blood types 73. B. provide selected cellular components as replacement therapy 72. keeping the system sterile b.. explain the procedure and instruct the client to report any side effects d. cardiac arrest. vascular collapse. shock. anxiety. blood group. bleeding. O. flushing. Two RNs must check the labels on the blood product to the client’s identification number. increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia c. itching. a. changing solutions. packed RBCs transfused in 2–4 hours 78. trauma. flushing. signed informed consent e. A. death Sudden chills and fever (rise in temperature of greater than 1° C). is the collection and reinfusion of a client’s own blood 77. a. nonhemoly -tic (most common) Mild allergic Sensitization to donor white blood cells. a technique in which a vein is punctured through the skin by a rigid stylet (butterfly). RBCs. an affiliate of Elsevier Inc. is an antigen antibody reaction and can range form mild response to severe anaphylactic shock. fever. urticaria Mosby items and derived items © 2009. or plasma proteins Sensitivity to foreign plasma Chills. assisting the client with self-care activities 71. a. stay with client for the first 15 minutes h. and complete name g. hypotension. acute renal failure. headache. or hemorrhage b. hemoglobinuria. type O 74. 2005 by Mosby.

Fad dieting – metabolic acidosis c.. a combination of increased PaCo2. anxiety with hyperventilation is a cause 92. Inc. 3. Extracellular fluid is all the fluid outside of the cell and has 3 compartments. and turn on NS that is connected to the Y-tubing infusion set. dyspnea. a. Steroid use – metabolic alkalosis b. 89. distended neck veins Rapid onset of chills. Hyperventilation – hyperventilation that occurs with conditions such as fever or anxiety causes the client to experience respiratory alkalosis by blowing off too much carbon dioxide with the increased respiratory rate. urticaria. Do not turn off the blood. monitor VS every 5 minutes. headache. possible cardiac arrest Cough. Any condition that results in the loss of GI fluids predisposes the client to the development of dehydration and a variety of electrolyte disturbances. headache. 81. and transfusion record are saved and returned to the lab. Prepare to administer emergency drugs per protocol. and an increased hydrogen ion concentration 90. hypertension. . anxiety. 84. diarrhea. Keep the IV line open with 0. tachycardia. 1. Obtain a urine specimen and send to lab (RBC hemolysis). vomiting. 91. Chronic alcoholism – respiratory acidosis Mosby items and derived items © 2009. d. 85.9% NS. flushing. 2005 by Mosby. pulmonary congestion (rales). attached labels. is marked by a decreased PaCO2 and an increased pH. 4.Study Guide Answer Key proteins Anaphylactic Infusion of IgA proteins to IgAdeficient recipient who has developed IgA antibody Fluid administered faster than the circulation can accommodate Transfusion of contaminated blood components (hives) Anxiety. 3. Notify health care provider. 82. shock. sudden chills and fever. Prepare to perform cardiopulmonary resuscitation. The blood container. excess carbonic acid. Remain with client. 88. high fever. an affiliate of Elsevier Inc. 87. tubing. and marked hypotension and shock 119 Circulatory overload Sepsis 79. observing signs and symptoms. muscle pain 80. wheezing progressing to cyanosis. 83. 86.

. b 10. . such as holding them snugly in blankets. e 18. Inc.Study Guide Answer Key Chapter 42: Sleep 1. j 5. I 3. an affiliate of Elsevier Inc. singing or talking softly. singing or talking softly. q 15. Infants usually develop a nighttime pattern of sleep by 3 months of age. d 11. The sleep cycle is generally 40 to 50 minutes with wakening occurring after one to two sleep cycles. The infant normally takes several naps during the day but usually sleeps an average of 8 to 10 hours during the night for a total daily sleep time of 15 hours. n 9. p 16. f 2. 2005 by Mosby. Quieting activities. a 8. such as holding them snugly in blankets. h 4. l 13. m 12. Mosby items and derived items © 2009. Developmental Stage Neonates 120 Infants Sleep Patterns The neonate up to the age of 3 months averages about 16 hours of sleep a day. help infants fall asleep. Approximately 50% of this sleep is REM sleep. and gentle rocking. k 7. which stimulates the higher brain centers. About 30% of sleep Usual Rituals Quieting activities. and gentle rocking. This is essential for development because the neonate is not awake long enough for significant external stimulation. g 6. sleeping almost constantly during the first week. help infants fall asleep. c 14. o 17.

or quiet activity) used consistently helps young children avoid delaying sleep. same hour for bedtime. By the age of 5. same hour for bedtime. After 3 years of age. . snack. an affiliate of Elsevier Inc. children usually sleep through the night and take daily naps. Partial wakening followed by normal return to sleep is frequent (Hockenberry and Mosby items and derived items © 2009. Preschoolers On average a preschooler sleeps about 12 hours a night (about 20% is REM). active days and has problems with bedtime fears. The preschooler usually has difficulty relaxing or quieting down after long. Parents need to reinforce patterns of preparing for bedtime. the preschooler rarely takes daytime naps except in cultures where a siesta is the custom (Hockenberry and Wilson. or nightmares. Parents need to reinforce patterns of preparing for bedtime. 2006).. snack or quiet activity) used consistently helps young children avoid delaying sleep. rocking the child to sleep.Study Guide Answer Key time is in the REM cycle. reading. although it is not unusual for an infant to awaken during the night. By the age of 2.. Total sleep averages 12 hours a day. 2005 by Mosby. During this period the toddler may be unwilling to go to bed at night due to a need for autonomy or a fear of separation from their parents.g. children often give up daytime naps (Hockenberry and Wilson. The percentage of REM sleep continues to fall. 2006). Quiet activities such as reading stories. A bedtime routine (e. It is common for toddlers to awaken during the night. waking during the night. reading. Awakening commonly occurs early in the morning.. allowing children to sit in a parent’s lap while listening to music or listening to a prayer are routines that are often associated with preparing for bed. or engaging in quiet play. Quiet activities such as reading stories. coloring. allowing children to sit in a parent’s lap while listening to music or listening to a prayer are routines that are often associated with preparing for bed. Some young children need a special blanket or stuffed animal when going to sleep.g. Inc. coloring. Reading the child a bedtime story. 121 Toddlers A bedtime routine (e.

Inc. watching an enjoyable television program. The amount of sleep needed during the school years. behavior and mood problems. Approximately 20% of sleep time is REM sleep. an affiliate of Elsevier Inc. teenagers get about 7½ hours of sleep per night. Most young adults average 6 to 8½ hours of sleep a night. The older child often resists sleeping because of an unawareness of fatigue or a need to be independent. and part-time jobs that reduce the time spent sleeping (National Sleep Foundation. or listening to Mosby items and derived items © 2009. This shortened sleep time often results in EDS. sleepwalking. whereas an 11-year-old sleeps about 9 to 10 hours (Hockenberry and Wilson. The 6. walking around. 2004. and increased use of alcohol are often the result of EDS due to insufficient sleep (Spilsbury and others. Reading a light novel. Performance in school. 2006b). A 6year-old averages 11 to 12 hours of sleep nightly. 2005 by Mosby. It is common 122 School-age children Adolescents Young adults Adults need to avoid excessive mental stimulation just before bedtime. the child exhibits brief crying.Study Guide Answer Key Wilson. 2005). unintelligible speech. 2006).or 7-year-old will usually go to bed with some encouragement or by doing quiet activities. which remains consistent throughout life. after-school social activities. The typical adolescent is subject to a number of changes such as school demands. vulnerability to accidents. In the waking period. Walsh and others. . or bed-wetting.. 2006). On average.

Guided imagery and praying also promote sleep for some clients Adults need to avoid excessive mental stimulation just before bedtime. Reading a light novel. deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see Older adults Mosby items and derived items © 2009. Episodes of REM sleep tend to shorten. Relaxation exercises such as slow. deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see Chapter 43). More than 50% of adults 65 years or older report problems with sleep (Hoffman. and social activities frequently to lead to insomnia and the use of medication for sleep. Daytime sleepiness contributes to an increased number of accidents. periodic limb movements. Inc. Complaints of sleeping difficulties increase with age. an affiliate of Elsevier Inc. and interpersonal problems in this age-group. decreased productivity. Insomnia is particularly common.. or listening to music helps a person relax.Study Guide Answer Key for the stresses of jobs. deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest (see Chapter 43). watching an enjoyable television program. family relationships. Reading a light novel. 2003). Pregnancy increases the need for sleep and rest. There is a progressive decrease in stages 3 and 4 NREM sleep. Relaxation exercises such as slow. The amount of stage 4 sleep begins to fall. restless leg syndrome. depression. or listening to music helps a person relax. 2005 by Mosby. . a decline that continues with advancing age. some older adults have 123 music helps a person relax. Guided imagery and praying also promote sleep for some clients. Women experiencing menopausal symptoms often experience insomnia. Middle adults Adults need to avoid excessive mental stimulation just before bedtime. watching an enjoyable television program. Relaxation exercises such as slow. and sleepdisordered breathing are common problems during the third trimester of pregnancy (Wolfson and Lee. or certain physical illnesses cause sleep disturbances. Anxiety. Insomnia. During middle adulthood the total time spent sleeping at night begins to decline. probably because of the changes and stresses of middle age. 2005).

or the death of a loved one 23. diuretics. and stimulants.Study Guide Answer Key almost no stage 4 sleep. and it takes more time for an older adult to fall asleep. benzodiazepines. or spicy meal at night often results in indigestion that interferes with sleep. Most persons are sleep-deprived and experience excessive sleepiness during the day. including hypnotics. Changes in sleep pattern are often due to changes in the CNS that affect the regulation of sleep. insomnia. performing unaccustomed heavy work. and changing evening mealtime 21. which can become pathological when it occurs at times when individuals need or want to be awake. 25. as are the size and firmness of the bed. alcohol. an older adult with arthritis frequently has difficulty sleeping because of painful joints. The presence of chronic illness often results in sleep disturbances for the older adult. caffeine. An older adult awakens more often during the night. 20. eating a large.. betaadrenergic blockers. engaging in late-night social activities. antidepressants. For example. . The tendency to nap seems to increase progressively with age because of the frequent awakenings experienced at night. Sensory impairment reduces an older person’s sensitivity to time cues that maintain circadian rhythms. Guided imagery and praying also promote sleep for some clients 19. Exercise 2 hours or more before bedtime allows the body to cool down and maintain a state of fatigue that promotes relaxation. caffeine. narcotics. 24. personal problems or certain situations frequently disrupt sleep. 124 Chapter 43). physical impairment. an affiliate of Elsevier Inc. rotating shifts will cause difficulty adjusting to the altered sleep schedule. and fatigue often result as a direct effect of commonly prescribed medications. anticonvulsants. weight loss or weight gain Mosby items and derived items © 2009. alcohol and nicotine produce insomnia. or deep sleep. Good ventilation is essential for a restful sleep. light levels affect the ability to fall asleep. retirement. Sleepiness. Inc. heavy. 22. 2005 by Mosby.

Study Guide Answer Key 125 26. Eliminate distracting noises. behaviors of sleep deprivation 28. and meats Mosby items and derived items © 2009. 40. 39. colas. 42. ineffective breathing pattern 30. increasing daytime activity lessens problems with falling asleep 47. sleep deprivation 37. plan care to avoid awakening clients for nonessential tasks. Client will report having fewer than 2 awakenings per night within 4 weeks. bedtime routines g. reduce the risk of post-op complications for clients with sleep apnea (airway). acute confusion 31. influences the pattern of major biological and behavioral functions 57. Client will identify factors in the immediate home environment that disrupt sleep in 2 weeks. bedtime environment h. ask a client to describe the number of awakenings during the previous night c. a. bed partners. melatonin (nutritional supplement to aid in sleep). cheeses. ineffective coping 33. void before retiring 46. keep beds clean and dry and in a comfortable position. use of CPAP 54. description of sleeping problems b. Client will report having a discussion with family members about environmental barriers to sleep in 2 weeks. splints. 2005 by Mosby. cautious use of sedatives 55. ineffective protection 35. family coping 32. promote comfortable room temperature. disturbed sleep pattern 38. usual sleep pattern c. anxiety 29. allow clients to determine the timing and methods of delivery of basic care 53. clothing. valerian. 3. fatigue 34. bedtime routines for children. small night light. definition of. sleep when fatigued or sleepy. pursue a relaxing activity for adults. disturbed sensory perception 36. and parents of children 27. a dairy product that contains L-tryptophan is often helpful to promote sleep. physical and psychological illness d.. an affiliate of Elsevier Inc. . current life events e. reduce noise. 41. and alcohol before bedtime 49. tea. children need comforting and night lights 48. adults need to avoid excessive mental stimulation before bedtime 44. Client will report changes made in the bedroom to promote sleep within 4 weeks. observe whether a client falls asleep after reducing noise and darkening a room b. and proper positioning 52. do not drink caffeine. giving clients control over their health care minimizes uncertainty and anxiety. lights. also refer to Box 42-12 in the text for other examples 51. Inc. a. clients. ventilation. a natural protein found in milk. kava 50. evaluate the level of understanding that clients and families gain after receiving instructions on sleep habits 56. bed and mattress to provide support and firmness 43. a bell at the bedside to alert family members 45. application of dry or moist heat. back rubs. extra blankets. 2. emotional and mental status f.

most physiological symptoms are decreased. Julie’s statement that she is having difficulty sleeping due to her husband’s snoring is an indication of an additional sleep problem.. 4. The related factor of the sleep disturbance is physiological for this client (leg pain). 60. 59.Study Guide Answer Key 126 58. 2. not increased. A sleep-promotion plan frequently requires many weeks to accomplish. and sleep hygiene habits is needed. A 1 – 2 week sleep log or diary with entries by both Julie and David can provide additional assessment data related to the problem. Mosby items and derived items © 2009. See Box 42-4 in the text for other symptoms of sleep deprivation. Inc. . 2005 by Mosby. an affiliate of Elsevier Inc. sleep habits. 61. history. A more in-depth assessment of David’s sleep problem. 4.

lasts longer than anticipated. j 5. fatigue c. muscle. type II). attention b. b. It is usually aching or throbbing in quality and is well-localized. f 3. Somatic: comes from bone. Neuropathic pain: Abnormal processing of sensory input by the peripheral or central nervous system. a. and pain is felt at least partly along the distribution of the damaged nerve. is of short duration. type I. has a cause. a. nerve entrapment. Obstruction of hollow viscus. Examples: Phantom pain reflects injury to the peripheral nervous system. pain that occurs sporadically over an extended duration of time b. c 2. family and social support Mosby items and derived items © 2009. Examples: nerve root compression. or connective tissue. e 9. a 7. which causes intermittent cramping and poorly localized pain. b 4. Examples: diabetic neuropathy. Visceral pain: Arises from visceral organs. 2005 by Mosby. a. Tumor involvement of the organ capsule that causes aching and fairly welllocalized pain. skin. is chronic in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition 14. Nociceptive pain: Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged. Sympathetically maintained pain: Associated with dysregulation of the autonomic nervous system. and Guillain-Barré syndrome. usually responsive to nonopioids and/or opioids. Mononeuropathies: Usually associated with a known peripheral nerve injury. treatment usually includes adjuvant analgesics. I 8. does not always have a cause. 15. . Inc. a. Examples: pain associated with reflex sympathetic dystrophy/causalgia (complex regional pain syndrome. Polyneuropathies: Client feels pain along the distribution of many peripheral nerves. Categories include: a. joint. k 11. g 10. previous experience c. such as the gastrointestinal tract and pancreas. Deafferentation pain: Injury to either the peripheral or central nervous system. trigeminal neuralgia.Study Guide Answer Key Chapter 43: Pain Management 127 1. an affiliate of Elsevier Inc.. age b. and has limited tissue damage and emotional response b. genes d. and leads to great personal suffering 13. d 12. is protective. alcohol-nutritional neuropathy. neurological function 16. burning pain below the level of a spinal cord lesion reflects injury to the central nervous system. h 6.

Study Guide Answer Key


17. active searching for meaning, concerns of loss of independence and becoming a burden to the family 18. a. anxiety b. coping styles 19. a. meaning of the pain b. ethnicity 20. A: Ask about pain regularly. Assess pain systematically. B: Believe the client and family in their report of pain and what relieves it. C: Choose pain-control options appropriate for the client, family, and setting. D: Deliver interventions in a timely, logical, and coordinated fashion. E: Empower clients and their families. Enable them to control their course to the greatest extent possible. 21. a. onset and duration b. location c. intensity d. quality e. pain pattern f. relief measures g. contributing symptoms h. effects of pain on the client i. behavioral effects j. influence on activities of daily living 22. anxiety 23. fatigue 24. hopelessness 25. impaired physical mobility 26. imbalanced nutrition: less than 27. powerlessness 28. chronic low self-esteem 29. disturbed sleep pattern 30. impaired social interaction 31. spiritual distress 32. reports that pain is a 3 or less on a scale of 0-10, does not interfere with ADLs, or personal pain intensity goal attained 33. identifies factors that intensify pain and modifies behavior accordingly 34. uses pain-relief measures safely 35. a. find such interventions appealing b. express anxiety or fear c. will possibly benefit from avoiding or reducing drug therapy d. are likely to experience and need to cope with a prolonged interval of postoperative pain e. have incomplete pain relief after use of pharmacological interventions 36. is mental and physical freedom from tension or stress that provides individuals with a sense of self-control 37. directs a client’s attention to something other than pain and thus reduces the awareness of pain 38. diverts the person’s attention away from the pain and creates a relaxation response 39. a massage, warm bath, ice bag, and TENS stimulates the skin to reduce pain perception by the release of endorphins, which block the transmission of painful stimuli 40. not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements 41. One simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery, music, and biofeedback 42. a. nonopioids b. opioids c. adjuvants/coanalgesics

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Study Guide Answer Key


43. a variety of medications that enhance analgesics or have analgesic properties that were originally unknown 44. allows clients to self-administer opioids with minimal risk of overdose; the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing 45. manage pain from a variety of surgical procedures with a pump that is set as a demand or continuous mode and left in place for 48 hours 46. EMLA via a disc or thick cream to the skin for 30 to 60 minutes before minor procedures 47. local infiltration of an anesthetic medication to induce loss of sensation to a body part 48. is the injection of a local anesthetic to block a group of sensory nerve fibers 49. it permits control or reduction of severe pain and reduces the client’s overall opioid requirement; can be short- or long-term 50. nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus 51. a. Prevent catheter displacement: Secure catheter (if not connected to implanted reservoir) carefully to outside skin. b. Maintain catheter function: Check external dressing around catheter site for dampness or discharge. (Leak of cerebrospinal fluid may develop.) c. Prevent infection: Use strict aseptic technique when caring for catheter (see Chapter 33). d. Monitor for respiratory depression: Monitor vital signs, especially respirations, per policy. e. Prevent undesirable complications: Assess for pruritus (itching) and nausea and vomiting. f. Maintain urinary and bowel function: Monitor intake and output. 52. a. 100 times more potent than morphine in predetermined doses that provide analgesic for 48-72 hours; useful when unable to take oral medications b. to treat breakthrough pain in opioid-tolerant clients, the unit is placed in the mouth and dissolved, not chewed 53. Incident pain: Pain that is predictable and elicited by specific behaviors such as physical therapy or wound-dressing changes End-of-dose failure pain: Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic Spontaneous pain: Pain that is unpredictable and not associated with any activity or event 54. Client: Fear of addiction, Worry about side effects, Fear of tolerance (won’t be there when I need it), Take too many pills already, Fear of injections, Concern about not being a “good” client, Don’t want to worry family and friends, May need more tests, Need to suffer to be cured, Pain is for past indiscretions, Inadequate education, Reluctance to discuss pain, Pain is inevitable, Pain is part of aging, Fear of disease progression, Primary health care providers and nurses are doing all that they can, Just forget to take analgesics, Fear of distracting primary health care providers from treating illness, Primary health care providers have more important or ill clients to see, Suffering in silence is noble and expected Health care provider: Inadequate pain assessment, Concern with addiction, Opiophobia (fear of opioids), Fear of legal repercussions, No visible cause of pain, Clients must learn to live with pain, Reluctance to deal with side effects of analgesics, Fear of giving a dose that will kill the client, Not believing the client’s report of pain, Primary health care provider time

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Study Guide Answer Key


constraints, Inadequate reimbursement, Belief that opioids “mask” symptoms, Belief that pain is part of aging, Overestimation of rates of respiratory depression Health care system barriers: Concern with creating “addicts,”, Ability to fill prescriptions, Absolute dollar restriction on amount reimbursed for prescriptions, Mail order pharmacy restrictions, Nurse practitioners and physician assistants not used efficiently, Extensive documentation requirements, Poor pain policies and procedures regarding pain management, Lack of money, Inadequate access to pain clinics, Poor understanding of economic impact of unrelieved pain 55. physical dependence: A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Addiction: A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addictive behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction: Client behaviors (drug seeking) that occur when pain is undertreated. Pseudotolerance: Need to increase opioid dose for reasons other than opioid tolerance: progression of disease, onset of new disorder, increased physical activity, lack of adherence, change in opioid formulation, drug-drug interaction, drug-food interaction. 56. a medication or procedure that produces positive or negative effects in clients that are not related to the placebo’s specific physical or chemical properties 57. treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures 58. the goal is to live life fully with an incurable condition 59. care of clients at the end of life, which emphasizes quality of life over quantity 60. evaluate the client for the effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the client’s perception of pain 61. 2. Only the client knows whether pain is present and what the experience is like. 62. 1. Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids (e.g., endorphins) which hinder the transmission of pain and help produce an analgesic effect. 63. 2. A client’s self-report of pain is the single most reliable indicator of the existence and intensity of pain. 64. 2. The reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input; with sufficient sensory stimulation a person is able to ignore or become unaware of pain. 65. 3. Developmental differences are found between age groups; therefore, the nurse needs to adapt approaches for assessing a child’s pain and how to prepare a child for a painful procedure. 66. Mrs. Mays, 75 years old, was diagnosed with a cancerous tumor in her left lung 2 months ago. She also has a history of osteoarthritis. After chemotherapy and radiation therapy, she

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unable to stay focused. 2005 by Mosby. Mosby items and derived items © 2009. Until today she was able to clean her home and climb the stairs to her bedroom without difficulty. Inc. and remains very still. so she doubled her medication and went to bed. or eat well. muscles tense and frowning. her pain escalated from a 3 to a 10. . Prior to being admitted to the hospital. she is now admitted to the hospital with uncontrollable chest pain and possible pneumonia. although a goal of 3 is preferable. She says that a pain intensity of 5 out of 10 helps her function better right now. She also maintained her body weight and slept well through the night. However. Currently her pain is a 9 on a 1-10 scale. but this did not help.. during the history taking. an affiliate of Elsevier Inc.Study Guide Answer Key 131 was taking ibuprofen 200mg on a prn basis. She responds that she is unable to complete her own hygiene activities. She is restless. sleep.

e 15. f 25. p 12. t 22.. b 27. I 4. d 33. k 8. i 37. v 9. u 21. a. suggested intake for individuals based on observed or experimental determined estimates of nutrient intakes d.Study Guide Answer Key Chapter 44: Nutrition 132 1. g 28. h 26. 2005 by Mosby. Inc. b 24. not the individual c. . r 16. j 7. f 13. o 6. an affiliate of Elsevier Inc. d 10. is the recommended amount of nutrition that appears sufficient to maintain a specific body function for 50% of the population based on age and gender b. n 18. l 20. a 23. m 32. l 29. s 11. n 5. k 30. e 34. q 17. j 31. m 14. is the average needs of 98% of the population. c 2. a 36. h 3. is the highest level that likely poses no risk of adverse health events Mosby items and derived items © 2009. g 19. c 35.

and fat-free or low-fat milk while staying within energy needs. eating at fast-food restaurants d. fad diets 45. Encourage physical activity.. inactivity c. 39. causes GI bleeding. an affiliate of Elsevier Inc. peer pressure e. 2005 by Mosby. a.Study Guide Answer Key 133 38. d. is too concentrated for infant’s kidneys to manage. a. correct temperature. a. increases time for mother and infant interaction 40. desire for independence c. fewer infant infections c. vegetables. with most fats coming from polyunsaturated or monosaturated fatty acids. diet rich in high-calorie foods b. poor source of iron and vitamin C and E 41. available and fresh e. Practice food safety to prevent microbial food-borne illness. Adopt a balanced eating pattern with a variety of nutrient-dense food and beverages among the basic food groups. b. increases the risk of mild product allergies. genetic predisposition c. physical readiness to handle different forms of foods c. Maintain body weight in a healthy range. Inc. whole-grain products. economical f. h. .g. f. family and social factors 44. body image and appearance b. use of food for coping mechanism for stress or boredom d. detect and control allergic reactions 43. weight loss leading to maintenance of body weight less than 85% Mosby items and derived items © 2009. are potential sources of botulism toxin and should not be used in the infant’s diet 42. the infant’s needs b. Choose and prepare foods and beverages with little added sugars or sweeteners. reduced food allergies and intolerances b. a. a. e. Choose and prepare foods with little salt while at the same time eating potassium-rich foods. i. e. g. Limit intake of alcohol. Keep total fat intake between 20-35 % of total calories. Encourage fruits. easier digestion d. c. and decrease sedentary activities. convenient. Anorexia nervosa: Refusal to maintain body weight over a minimal normal weight for age and height.. a.

. and decreased esophageal and colonic peristalsis b. physical functional level to meet activities of daily living (ADLs). 48. diabetes mellitus. e. and poultry but eat eggs and milk 49. or shape is experienced.g. decreased thirst sensation. The presence of chronic illnesses (e. eat only fruits. presence of nutrition impact symptoms b. the person claims to “feel fat” even when emaciated. is important for DNA synthesis and the growth of RBCs. and impaired smell and taste perception. e. size. A minimum average of 2 binge eating episodes a week for at least 3 months. loneliness. and depression affect ability to obtain. a. an affiliate of Elsevier Inc. dependency. screening for malnutrition for risk factors (unintentional weight loss. or phosphorus for basic metabolic demand (BMD). avoid meat. atrophy of oral mucosal epithelial cells. Inc. total iron-binding capacity. Bulimia nervosa: Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time). lab and biochemical tests (albumin. Disturbance in the way in which one’s body weight. and eat healthy foods. such as income. transferring. or vigorous exercise in order to prevent weight gain. B12 may not be synthesized because of lack of intrinsic factor in terminal ileum. prealbumin. use of laxatives or diuretics. end-stage renal disease. BMI d. absence of at least 3 consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). decreased lean muscle mass. inadequate intake will lead to possible neural tube defects. early satiety. xerostomia. In females.up of the body) c.Study Guide Answer Key 134 of IBW. presence of a modified diet. c. Intense fear of gaining weight or becoming fat. anencephaly or maternal. Cognitive impairments such as delirium. reduced gag reflex. d. drink milk but avoid eggs 50. and transportation. fish. increased taste threshold. Age-related gastrointestinal changes that affect digestion of food and maintenance of nutrition include changes in the teeth and gums. and herb teas 51.) b. believes that one area of the body is “too fat” even when obviously underweight. Factors affecting nutrient needs: Calcium.g. A feeling of lack of control over eating behavior during the eating binges.. a. lower basic energy expenditure (BEE) f. and olive oil 52. eat primarily brown rice. vitamin D. leading to body weight less than 85% of that expected. although underweight. prepare. and hemoglobin) Mosby items and derived items © 2009. administration. Malnutrition in older adults has multiple causes. . cancer) often affect nutrition intake. loss. dementia. or failure to make expected weight gain during period of growth.. other grains.g. nuts. anthropometry (size and make. (A woman is considered to have amenorrhea if her periods occur only following hormone. e. strict dieting or fasting. educational level. estrogen. megaloblastic anemia 47. retinal binding protein. 2005 by Mosby. 46. reduced saliva production. Adverse effects of medications cause problems such as anorexia. The person regularly engages in either self-induced vomiting. honey..

weakness u. petechiae. tongue: Swelling. dry. scaly. abnormal rhythm. eyes: Eye membranes pale (pale conjunctivas). neck (glands): Thyroid or lymph node enlargement s. brittleness. myogenic. elevated blood pressure h. constipation or diarrhea. dull. hair: Stringy. malpositioned q. signs of infection. redness of membrane (conjunctival injection). beefiness (glossitis). inflammation. atrophic papillae p. indigestion. imbalanced nutrition: less than body requirements Mosby items and derived items © 2009. lips: Dry. “wasted” appearance. swollen. boggy oral mucous membranes n. apathetic. redness and fissuring of eyelid corners (angular palpebritis). cachectic b. dryness of eye membrane (conjunctival xerosis). 2005 by Mosby. and sparse. ridges t. risk for aspiration 56. depigmented. redness and swelling (cheilosis). soft cornea (keratomalacia) r. irritated. subcutaneous fat loss k. tingling. muscles: Flaccid. Bitot’s spots. Inc. an affiliate of Elsevier Inc. pigmented. scaly. general vitality: Easily fatigued. face and neck: Greasy. teeth: Unfilled caries. scarlet and raw. . prominent scapulae and ribs 55. dry. gums: Spongy gums that bleed easily. poor tone. oral membranes: Swollen. weakness and tenderness of muscles (may result in inability to walk). and obstructive causes) 54. fissures or scars (stomatitis) m. irritability. underdeveloped tone. enlarged heart. posture: Sagging shoulders. loss of position and vibratory sense. diarrhea 58. worn surfaces. hyperemic and hypertrophic papillae. legs. marginal redness.. cardiovascular: Rapid heart rate (above 100 beats/min).Study Guide Answer Key 135 e. burning and tingling of hands and feet (paresthesia). missing teeth. health-seeking behaviors 59. pale. falls asleep easily. angular lesions at corners of mouth. a. dietary history 53. dull appearance of cornea (corneal xerosis). scaly. no energy. dryness. tender calf. deficient knowledge 60. magenta. decrease or loss of ankle and knee reflexes. absent vibratory sense f. humped back d. general appearance: Listless. knock-knees. receding o. sunken chest. brittle. constipation 57. weight: Obesity (usually 10% above IBW) or underweight (special concern for underweight) c. nail: Spoon shape (koilonychia). skin: Rough. impaired ability to walk properly e. mottled (fluorosis). swollen. mouth. difficulty swallowing (neurogenic. chest deformity at diaphragm. feet: Edema. thin. easily plucked j. nervous system: Inattention. skeleton: Bowlegs. lumpiness or flakiness of skin around nose and mouth l. gastrointestinal: Anorexia. confusion. liver or spleen enlargement g. bruises. discolored. tired and apathetic i. dark skin over cheeks and under eyes.

smoked and salted fish.0-3. egg dishes. salads g. risk for imbalanced nutrition: more than body requirements 63. perspiration. readiness for enhanced nutrition 64. a. imbalanced nutrition: more than body requirements 62. decreased level of alertness. appropriate assessment of nutrition needs Mosby items and derived items © 2009. a. staphylococcus: Severe abdominal cramps. a. minimizes the hypermetabolic response to trauma c.0-2. not nutritionally complete c. shigellosis: Milk. 2005 by Mosby. a. custards. seafood. feeding self-care deficit 65. (1. Appears 1-6 hours after ingestion and lasts 1-2 days 67. prostration. a. unpasteurized milk.. reduces sepsis b. lunch meats). removes sugared beverages from the diet d.0 kcal/mL) milk-based blenderized foods b. perfringens enteritis: Cooked meats. botulism: Improperly home-canned foods. sandwich fillings. meat dishes held at room or warm temperature e. and clients who have difficulty managing saliva 68. salad dressings. nectar-like liquids (medium viscosity) c.0 kcal/mL) designed to meet specific nutritional needs in certain illnesses 71. an affiliate of Elsevier Inc. listeriosis: Soft cheese.8 – 4. dysphagia advanced d. (1. a. (1.0 kcal/mL) predigested nutrients that are easier for a partially dysfunctional GI tract to absorb d. meat (hot dogs.0-2. fat nutritional intake is less than 30% c. pain. escherichia: Undercooked meat (ground beef) c. milk products. polluted shellfish f. pate. refrains from eating unhealthy foods between meals and after dinner e. . diarrhea. loses at least ½ to 1 pound per week 66. fever. shellfish b. salmonellosis: Milk. vomiting. nutritional intake meets the minimal DRIs b. seafood d. sausage. maintains intestinal structure and function 72. (3. dysphagia mechanically altered c. decreased gag and/or cough reflexes. honey-like liquids d.Study Guide Answer Key 136 61. headache. dysphagia puree b. ham.0 kcal/mL) single macronutrient preparations. thin liquids (low viscosity) b. spoon-thick liquids (pudding) 70. Inc. poultry. regular 69. a.

Hypoglycemia: Diaphoresis. provide supplemental kcal and prevent fatty acid deficiencies 74. Hyperglycemia: Thirst. Reaction of incompatible medications or formula e. careful monitoring to prevent or treat metabolic complications 73. is the use of nutritional therapies to treat an illness. carbohydrates 45-75%. injury. and avoiding lactose. Lactose intolerance. High-fat formula used. celiac disease. headache. shakiness. or diabetes mellitus i. once the client meets 1/3 to ½ of their kcal needs per day. renal insufficiency.0. and CO2 levels b. Antibiotic therapy. confusion. Serum electrolyte imbalance: Excess GI losses. increase the EN to meet needs (75%) 77. severe signs of dehydration (see Chapter 41). coma 76. Diarrhea: Hyperosmolar formula or medications. limit fat to less than 7%. Tube occlusion: Pulverized medications given per tube. Presence of disease states such as cirrhosis.Study Guide Answer Key 137 b. Mg. Pulmonary aspiration: Regurgitation of formula. Rapid increase in rate/volume. serum osmolarity >350 mOsm/L. Ca. 80. fish at least twice per week. treat with moderate-to-low residue and high-fiber diet 82. supplemental vitamins. Hyperosmolar dehydration: Hypertonic formula with insufficient free water 75. a. PN is usually decreased to ½ the original volume. increased CO2. convulsions. Inc. . is a bacteria that causes peptic ulcers and is confirmed by lab tests. PO4. balancing caloric intake with exercise. metabolic acidosis. respiratory quotient >1. hypernatremia. Bacterial contamination. or condition 78. reducing fat. Constipation: Lack of fiber. Crohn’s disease and ulcerative colitis: treat with elemental diets or PN. and whole-grain fiber. Serious illnesses. azotemia. Intestinal obstruction. cholesterol less than 200 mg/day 83. diet high in fruits. Fluid overload: Refeeding syndrome in malnutrition. gluten-free diet 81. Tube displacement: Coughing. an affiliate of Elsevier Inc. Not taped securely f. Malabsorption c. and iron. Delayed gastric emptying b. glycosuria. Electrolyte imbalance: Monitor Na. vomiting. meticulous management of the CVC line c. treated with antibiotics 79. Hypercapnia: Increased oxygen consumption. K. Abdominal cramping. Cl. Sedimentation of formula. confusion. nausea/vomiting: High osmolality of formula. heart failure. Delayed gastric emptying: Diabetic gastroparesis. limit food high in added sugar and salt 84. Manage by increasing fiber. Inactivity d. Excess free water or diluted (hypotonic) formula j. loss of consciousness d. lethargy. headache. Cold formula used g.. Inactivity h. avoiding large meals. minute ventilation c. Dehydration. Lack of free water. increased urination e. goal is to meet the increased metabolic needs of the client by maximizing intake of nutrients and fluids Mosby items and derived items © 2009. vegetables. 2005 by Mosby. Deficient gag reflex. Hyperglycemic hyperosmolar nonketotic dehydration/coma (HHNC): Hyperglycemia (>500 mg/dl). Feeding tube displaced. a.

dull. pale conjunctivae and mucous membranes. Her friends at church call her to come back to meetings. She says she tires easily. 2. 3. Mrs. psychologist. Her weight is 20% below her IBW and her BMI is 17. Cooper has stooped posture. 2005 by Mosby. Cooper states that she drinks some juice in the morning and two or three cups of coffee. and cell function of the renal medulla 88. 2+ bilateral pitting ankle edema. Cooper. Her physical assessment and laboratory values will be within normal limits. Cooper responded that it was tight living on a small pension and Social Security. Mrs. the growth rate slows during the toddler years (1-3) and therefore needs fewer kcal but an increased amount of protein in relation to body weight. 4. All of the other clients are at risk for a nutritional imbalance. In addition. Cooper about the food pyramid. 92. Cooper noticed a weight loss (15%). who is 68 years old and has a history of congestive heart failure. 1. Cooper started taking sertraline for depression related to the loss of her husband 6 months ago. including 50 g of protein per day. appetite often decreases at 18 months of age 90. ongoing comparisons need to be made with baseline measures of weight. “I’m just not interested in food. and registered dietitian.” Mrs. the nurse practitioner will coordinate plan of care with healthcare provider. changes in condition 87. 91. an affiliate of Elsevier Inc. Cooper complains of loneliness and said she does not get out much. 4. Recently Mrs. . although her psychologist recommended more socializing. Goals for this patient include gaining 1 to 2 pounds per month until goal of 130 pounds is reached by consuming 1900 kcal/day. Cooper to eat lunch at the senior center 5 times per week. and protein and kcal intake. Cooper states. Mrs. nutrient-dense meals that limit fatty foods and overly sweet foods 86. which is used for building. and total lymphocyte count (TLC). skeletal muscles during exercise . Mosby items and derived items © 2009. Cooper was also referred for counseling 3 months ago for help with grief and depression through a local senior service agency. but she was able to manage. 2. and generalized poor muscle tone. She has lost 24 pounds over the past 6 months. thinning hair. Mrs. the recommended diet from the AHA to reduce risk factors for the development of hypertension and coronary heart disease 93. Each gram of CHO produces 4 kcal and serves as the main source of fuel (glucose) for the brain. scaling skin. Cooper will be monitored monthly for weight gain. but she is just not ready. Mrs. repairing. Inc. The nurse practitioner will encourage Mrs. anemia. Three months have passed since Mrs. to help offset anorexia secondary to sertraline. including fluids and fiber. small. It has no taste. erythrocyte and leukocyte production. serum albumin. When Maria inquired as to her financial situation. is when the intake of nitrogen is greater than the output. The measurement of pH of secretions withdrawn from the feeding tubes helps to differentiate the location of the tube.. she often has a sandwich in the late afternoon. serum albumin level. She will encourage client to eat small meals and to increase dietary intake. and replacing body tissues 89.Study Guide Answer Key 138 85. frequent. She will individualize her menu plans and teach Mrs. Mrs. Mrs. dry. In order to accomplish these goals.

a. fluid balance e. a tube is placed directly into the renal pelvis to drain urine directly from one or both of the kidneys 20. dietary modifications and administration of medications to correct electrolyte abnormalities). an excessive amount of urine c. g 24. pattern of urination b. hematuria 17. Worsening of uremic syndrome associated with ESRD (i. sociocultural factors c. the client wears a stomal pouch continuously 19. f 31. vomiting. hyperkalemia. nausea. fistulas. 7. awakening to void one or more times at night b. no urine 12.g. b 29. an increase in nitrogenous wastes in the blood. pericarditis). cystitis. Severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures (e. ureters are implanted into the isolated segment of ileum and used as a conduit for continuous drainage. factors affecting urination 21. Renal failure that can no longer be controlled by conservative management (i.e. symptoms of urinary alterations c. psychological factors d. 3.. pathological conditions (acute. 2005 by Mosby. retained urine in the bladder from kinked. 6. a 1. and convulsions 10. Escherichia coli most common pathogen 15.Study Guide Answer Key Chapter 45: Urinary Elimination 139 d c g f b e a a. surgical and diagnostic procedures 9. chronic) b. neurological changes. urine output < intake d. dysuria.e. an affiliate of Elsevier Inc.. 2. vomiting and malaise. or clamped catheter 16. vomiting. radiation to the bladder. headache. cancer of the bladder. chills. nausea. pulmonary edema) 11. h 26. 4. has a stoma on the abdomen to drain the urine 13. k 27.. Mosby items and derived items © 2009. or chronic cystitis 18. obstructed. . fever. hospital-acquired result from catheterization or surgical manipulation. Inc. nausea. d 30. l 28. e 23.. j 22. marked fluid and electrolyte abnormalities. 5. surgical formation (temporary or permanent) that bypasses the bladder. is an accumulation of urine resulting from an inability of the bladder to empty properly 14. trauma. coma. 8. I 25.

rinse area with sterile water. Male – After donning sterile gloves. protein (none or up to 8 mg/100 ml). urethral meatus 34. d. Client finishes voiding in bedpan or toilet. Using a fresh swab each time. After the nurse wipes the port with an antimicrobial swab. and dry with cotton or gauze. ketones (none). and crystals (none). transfer the urine to a sterile container. and using circular motion and antiseptic swab. appears transparent at voiding. collect a sterile specimen by using aseptic technique through the special sampling port (Figure 45-7) found on the side of the catheter. a. allowing fresh. rinse area with sterile water. the stronger the odor 37. Clamp the tubing below the port. pale. spread labia with thumb and forefinger of nondominant hand. and the urine is transferred to the special collection container. then left side then right side). c. has a characteristic odor. Remove specimen container before flow of urine stops and before releasing labia or penis. retract the foreskin before cleansing. repeat front-to-back motion three times (begin with center. cleanse end of penis. blood. specific gravity (1. moving from front (above urethral orifice) to back (toward anus). will analyze values of pH (4.030) and microscopic values for RBCs (up to 2). or 24-hour collections. hold penis with one hand. WBCs (0-4 per low-power field). the more concentrated the urine.While continuing to hold labia apart. Missed specimens make the whole collection inaccurate. Sterile: If the client has an indwelling catheter. 12-. .6-8. Using sterile aseptic technique. sterile or clean voided sample of urine and can report bacterial growth in 24-48 hours 41. Use a clean specimen cup. If agency procedure indicates. 38.Study Guide Answer Key 140 32. Remove specimen container before flow of urine stops and before releasing labia or penis. an affiliate of Elsevier Inc. The timed period begins after the client urinates and ends with a final voiding at the end of the time period. bacteria (none). kidneys. which often contains special preservatives. bladder. 39. If agency policy indicates. have client initiate stream. moving from center to outside (see illustration). uncontaminated urine to collect in the tube. casts (none). 2005 by Mosby. Each specimen must be free of feces and toilet tissue.0). and dry with dry cotton ball or gauze. b. After client has initiated urine stream. insert a sterile syringe hub and withdraw at least 3 to 5 ml of urine (check agency policy). Timed urine: Time required may be 2-.0053-1. is the weight or degree of concentration of a substance compared with an equal volume of water 40. The client voids into a clean receptacle. Cleanse area with cotton ball or gauze. becomes more cloudy on standing in a container 36. Check with agency policy and the laboratory for specific instructions. c 33. In uncircumcised men.. glucose (none). Female – After donning sterile gloves. pass specimen collection container into stream. After client achieves a stream. Mosby items and derived items © 2009. Client finishes voiding in bedpan or toilet. skin and mucosal membranes. Inc. pass container into stream and collect 30 to 60 ml. Random: Collect during normal voiding from an indwelling catheter or urinary diversion collection bag. Clean-voided or midstream: Use a sterile specimen cup. and collect 30 to 60 ml. straw-colored to amber-colored depending on its concentration 35.

weight loss. A catheter is placed in one of the femoral arteries and introduced up to the level of the renal arteries. urinary retention 51. general anesthesia or conscious sedation is more common to avoid unnecessary anxiety and trauma for the client. endoscopy: Direct visualization. client will void within 8 hours b. 42. urodynamic testing: Determine bladder muscle function. This procedure is indicated to evaluate causes of urinary incontinence. Although this procedure is usually performed using local anesthesia. Inc. pain (acute. urinary incontinence (functional. and electronic data is recorded and analyzed. surgical interventions. client’s bladder is not distended to palpation 52. normal positioning b. a. a. and urethra. c. functional: Clothing modifications. Surgery on the male prostate is also performed using a special endoscope. scheduled toileting. urge) 45. warm water over the client’s perineum 53. impaired urinary elimination 50. Can also be used to estimate the volume of urine in the bladder. absorbent products stress: Pelvic floor exercises (Kegel). symmetry. lifestyle modifications (smoking cessation. Abdominal roentgenogram: Determine the size. bladder. and fluid modifications). Ultrasound: Renal – Identify gross renal structures and structural abnormalities in the kidney using high-frequency. Radio-opaque contrast is injected through the catheter while xray images are taken in rapid succession. d. electrical stimulation. biofeedback. Bladder – Identify structural abnormalities of bladder or lower urinary tract. inaudible sound waves. disturbed body image 44. shape. . toileting 48. A special intravenous injection (iodine-based) that converts to a dye in urine is injected intravenously. stress. absorbent products urge: Antimuscarinic agents. urinary output of 300 ml or greater will occur with each voiding c. Intravenous pyelogram (IVP): View the collecting ducts and renal pelvis and outline the ureters. Generally the client urinates into a toilet equipped with a funnel and uroflowmeter.Study Guide Answer Key 141 a. 43. biofeedback. and location of the kidneys. e. impaired skin integrity 49. bladder retraining. running water c. 2005 by Mosby. The computer reconstructs cross-sectional images and thus allows the health care provider to view pathologic conditions such as tumors and obstructions. specimen collection. self-care deficit. CT scan: Obtain detailed images of structures within a selected plane of the body. an affiliate of Elsevier Inc. absorbent products Mosby items and derived items © 2009. Voiding activates the uroflowmeter. environmental alterations. risk for infection 47. b. behavioral interventions. and/or treatment of the interior of the bladder and urethra. pelvic floor exercises. chronic) 46. stroking the inner aspect of the thigh d. Arteriogram: Visualizes the renal arteries and/or their branches to detect narrowing or occlusion..

provision of decompression. effective in treating stress incontinence. by improving voluntary control over urination 65. to maintain the patency of indwelling catheters. surgical placement of a catheter through the abdominal wall above the symphysis pubis and into the urinary bladder 61. or incompetent bladders short-term indwelling: Obstruction to urine outflow (e. and mixed causes of urinary incontinence 63. must be able to physically manipulate equipments and assume positions 66. 3. N/V. Antibiotics help the situation. the other choices are interventions to teach the client to prevent UTI. 4. 71. ulcers. special care TID and after defecation 58.. .. Skin rashes. 2000-2500 ml if permitted 59. intermittent: Relief of discomfort of bladder distention. involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contraction 68. whole-grain breads. blood. 2005 by Mosby. Obtaining sterile urine specimen when clean-catch specimen is unobtainable. specific for clients with urge incontinence related to overactive bladder 64. Mosby items and derived items © 2009. or sediment can collect within the tubing and result in bladder distention and buildup of stagnant urine 60. chills. prostate enlargement). pus. eggs. and malaise 69. urethra. Long-term management of clients with spinal cord injuries. pain or burning (dysuria) as well as fever.Study Guide Answer Key 142 mixed: Main treatments will usually be based on the symptoms that are most bothersome to client reflex: Intermittent catheterization.g. and prunes 55. Continuous or intermittent bladder irrigations long-term indwelling: Severe urinary retention with recurrent episodes of UTI. overactive bladders. or wounds irritated by contact with urine. clients with chronic disorders such as spinal cord injuries. Assessment of residual urine after urination. meat. Credé’s method 54. and surrounding structures. Measurement of urinary output in critically ill clients. benefits clients with functional incontinence. symptoms of an allergic response 70. evaluate for change in the client’s voiding pattern and continued presence of urinary tract alterations 67. 2. suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying 62. Inc. Terminal illness when bed linen changes are painful for client 56. is to reduce the voiding frequency and to increase the bladder capacity. personal hygiene at least BID for a client with an indwelling catheter with soap and water 57. cranberries. Prevention of urethral obstruction from blood clots after genitourinary surgery. improves the strength of pelvic muscles and consists of repetitive contractions of muscle groups. Surgical repair of bladder. 1. an affiliate of Elsevier Inc. neuromuscular degeneration. condom catheter (male).

“You know. I have problems being intimate with my husband because of leaking. and being overweight (200 lbs and 5’ 1” tall). I dribble easily just picking something up or when I’m on my way to the bathroom. . being postmenopausal. addressing urinary leakage and other lower urinary tract symptoms. Mrs. The history will help define the proper interventions. Mrs. an affiliate of Elsevier Inc. Grayson begins to cry and states. Grayson about any other effects that her leakage has caused. She has not spoken to anyone about her problems because she is embarrassed. The report of urine leakage upon physical exertion. If my bladder is a little full.. Mosby items and derived items © 2009. It is safer to stay home. She states that she has been wearing “one of those little pads” all the time now. Grayson what she has been doing about her condition. Her risk factors for this condition include a history of three pregnancies. She has recently begun Kegel’s exercises to attempt improvement in her urinary control. I’m afraid to laugh any more as that is another time I leak urine. sneezing.” The nurse asks Mrs. The nurse had the client describe situations that accompany urine leakage.” The nurse takes a focused nursing history. 2005 by Mosby. She responds.Study Guide Answer Key 143 Mrs. “I find myself being embarrassed and frustrated for losing control. and laughing increases the likelihood of a diagnosis of stress incontinence. I don’t even like to go out to the movies or a party anymore. The nurse asks Mrs. We used to go to dancing occasionally but we don’t do that anymore. Grayson is a 55-year-old woman who has had problems with stress incontinence for the past 2 years. At work I try to avoid being close to my coworkers because I am afraid I might have an odor. Inc. Grayson finally confides to her healthcare practitioner that the problem is causing her to avoid social situations and that she would like help to regain urinary control.

and rectum. Missed defecation signal increasing risk for fecal incontinence f. the external sphincter relaxes and the abdominal muscles contract. fresh fruits. small intestine: Increase in pouches on the weakened intestinal wall called diverticulosis e. a. fluid liquefies the intestinal contents. chime mixes with digestive juices 5. motor activity. and abdominal surgery 16. aid in control of defecation 7. stomach: Decrease in acid secretions. and empties its contents into the small intestine. sights and sounds and odors of toilet facilities d. 2005 by Mosby. esophagus: Reduced motility. reduced fluid intake slows the passage of food through the intestine and results in hardening of stool contents 12. and pepsin and intrinsic factor. increasing intrarectal pressure and forcing the stool out. nutrient absorption d. irritable bowel syndrome. liver: Size decreased 9.. ulcerative colitis. . weakened abdominal and pelvic floor muscles impair the ability to increase intra-abdominal pressure and to control the external sphincter 13. mixing of food. It is the primary organ of elimination. 3. a non-digestible residue in the diet that provides the bulk of fecal material (whole grains. hemorrhoids.Study Guide Answer Key Chapter 46: Bowel Elimination 144 1. easing its passage through the colon. and saliva is produced to dilute and soften the food for easier swallowing 2. persons who lack the enzyme needed to digest the milk sugar 11. general anesthetic agents used during surgery cause temporary cessation of peristalsis. 6. colon. especially in lower third c. a. Pressure can be exerted to expel forces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. contraction and relaxation of the internal and external sphincters. rectal fistulas. large intestine: Constipation. liquid and digestive juices. mucosal thickness. and vegetables) 10. lower GI tract (colon) divided into the cecum. an affiliate of Elsevier Inc. direct manipulation of the bowel temporarily stops peristalsis (paralytic ileus) 17. stores swallowed food and liquid. a busy work schedule b. embarrassment of using bedpans 15. segmentation and peristaltic movement facilitate both digestion and absorption. at the time of defecation. breaking it down to swallow. hospitalized clients who lack privacy C. certain gastric and duodenal ulcers. including oral dryness b. 8. produces HCL. which is essential for the absorption of Vitamin B12 4. innervated by sympathetic and parasympathetic stimuli. Teeth masticate food. Mosby items and derived items © 2009. The bolus of food travels down and is pushed along by peristalsis. Inc. promotes peristalsis. mouth: Decreased chewing and decreased salivation. mucus. which propels the food through the length of the GU tract. rectal surgery. and Crohn’s disease 14.

an affiliate of Elsevier Inc. a collection of hardened feces wedged in the rectum that a person cannot expel as a result of unrelieved constipation 24. antispasmodics. colonoscopy and endoscopy 19. absorption. anticholinergics cause constipation. nausea and/or vomiting d. Older adults often eat low-fiber foods.Study Guide Answer Key 145 a. Organic illnesses such as hypothyroidism. improper diet. or rectal surgery b. Medications such as anticholinergics.. a. 18. depression.. calcium supplements. iron: Causes discoloration of the stool (black). Low-fiber diet high in animal fats (e. hypocalcemia. elevated intraocular pressure d. eating disorders) c. NSAIDs: Cause gastrointestinal irritation that increases the incidence bleeding with serious consequences to the elderly f. anticonvulsants. dairy products. lack of exercise. . diabetic neuropathy. d. and abdominal cramps. or hypokalemia j. Antibiotics: Produce diarrhea by disrupting the normal bacterial flora in the GI tract. rectal pain 25. meats.g. Neurological conditions that block nerve impulses to the colon (e.. Parkinson’s disease. and opioids slow colonic action. Inc. Lengthy bed rest or lack of regular exercise f. and secretion Mosby items and derived items © 2009. GYN. rheumatoid arthritis. d. difficile. unformed feces associated with disorders affecting digestion. 2005 by Mosby. 22. inability to defecate at will. Narcotics: Slow peristalsis and segmental contractions.g. iron supplements. it interferes with the formation and production of protective mucus and causes GI bleeding. infrequent bowel movements < 3 days. h. Irregular bowel habits and ignoring the urge to defecate b. tumor) i. e. Dicyclomine HCl (Bentyl): Suppresses peristalsis and decreases gastric emptying b. An increase in the use of fluoroquinolones in recent years has provided a selective advantage for the epidemic of C. g. eggs). Chronic illnesses (e. cardiovascular disease c.. cognitive impairment e. increased intracranial pressure 23. chronic bowel diseases. diuretics. (diarrhea is less commonly reported). bile acid sequestrants. abdominal distention and cramping e. reduced fluid intake. is an increased number of stools and the passage of liquid. loss of appetite (anorexia) c. antidepressants. excessive straining. Laxative misuse g. oozing of diarrhea b. antacids. Anxiety. a. hard feces 21. antihistamines. certain medications 20. Older adults experience slowed peristalsis. nausea. often resulting in constipation c. depression. loss of abdominal muscle elasticity. vomiting. aspirin: A prostaglandin inhibitor. Histamine2 (H2) antagonists: Suppress the secretion of hydrochloric acid and interfere with the digestion of some foods h. Although useful in treating hyperactive bowel disorders. low fluid intake slows peristalsis. constipation. difficulty passing stools. antihypertensives. and reduced intestinal mucus secretion. antiparkinsonism drugs. spinal cord injury.g. a. Also. multiple sclerosis. abdominal. Anticholinergics: Inhibit gastric acid secretion and depress GI motility.

cells lining intestinal mucosa. daily or 2 to 3 times a week e. formed d. presence and status of bowel diversions f. surgical opening in the ileum 32. all 4 quadrants for contour. social history o. and a double-barrel colostomy 34. symmetry. or gas 39. and chronic liver disease 30. 2005 by Mosby. Bladder b. loop colostomy. which measures microscopic amounts of blood in feces. fluid and electrolyte or acid-base imbalances 27. diet history h. invasive bowel procedures. artificial opening in the abdominal wall 31. Consistency: Soft. stretches and distends (a common cause of abdominal fullness. Upper Endoscopy d. history of surgery or illness j. changes in appetite g. surgical opening in the colon 33. bile pigment. a. a gas accumulation in the lumen of the intestine. Shape: Resembles diameter of rectum g. history of exercise m. Constituents: Undigested food. Color: Infant: yellow. pregnancy. assessment of the use of artificial aids at home e. description of daily fluid intake i. Plain Film of Abdomen/Kidneys. history of pain or discomfort n. increased venous pressure from straining and defecation. Frequency: Varies: Infant. mobility and dexterity 35. client’s description of usual stool characteristics c. affected by food type c. chemotherapy. fluid.Study Guide Answer Key 146 26. Colonoscopy g. or guaiac test. 4 to 6 times daily (breast-fed) or 1 to 3 times daily (bottlefed). is the inability to control passage of feces and gas from the anus caused by physical conditions that impair anal sphincter function or control b. for masses or areas of tenderness 38. detects lesions. Upper GI/Barium Swallow c. water 41.. shape. medication history k. Ureter. Computerized Tomography Scan Mosby items and derived items © 2009. . fat. Inc. Amount: 150 g per day (adult) f. adult. dead bacteria. or from a health care worker’s hands or direct contact with environmental surfaces 28. assess bowel sounds in all 4 quadrants 37. useful as a screening tool for colon cancer 40. contamination and risk of skin ulceration b. a. end colostomy. a. emotional state l. adult: brown b. heart failure. Barium Enema e. pain. identification of routines followed to promote normal elimination d. Flexible Sigmoidoscopy h. a. Ultrasound f. and cramping) 29. an affiliate of Elsevier Inc. a. Odor: Pungent. determination of the usual elimination pattern b. and skin color 36. a causative agent of mild diarrhea to severe colitis acquired by the use of antibiotics.

assess the condition of the nares and mucosa for inflammation and excoriation. constipation 44. Compression d.. it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel 60. normal saline. emollient or wetting. self-care deficit: toileting 48. can cause irritation to the mucosa. saline. provide relief from gaseous distention. positioning on bedpan c. frequent changing of the tape and lubrication of the nares. . Inc. and bowel training 57. stimulant. client does not report any discomfort associated with defecation 53. Enteroclysis 42. is hypotonic and exerts a lower osmotic pressure than fluid in interstitial spaces 59. assessing the normal elimination pattern and recording times when the client is incontinent 69. Antidiarrheal opiate agents decrease intestinal muscle tone to slow passage of feces. include tap water. client implements a regular exercise program 51. formed brown stool 52. safest solution. and low-volume hypertonic saline 58. client reports daily passage of soft. have the short-term action of emptying the bowel (bulk forming. contraindicated in clients who are dehydrated and in young infants 61. 2005 by Mosby. a. an affiliate of Elsevier Inc. creates the effect of interstitial irritation to stimulate peristalsis 62. Magnetic Resonance Imaging j. risk for constipation 45. perceived constipation 46. Enteral Feeding c. Lavage 67. emptying the bowel before diagnostic tests. diarrhea 47. which results in a reflex slowing of the heart rate 66. client is able to list proper fluid and food intake needed to achieve elimination 50. a. soapsuds solution. temporary relief of constipation. 56. that the enema is repeated until the client passes fluid that is clear and contains no fecal material 65. medications 54. Decompression b. privacy d. bleeding. lubricate the rectum and the colon and make the feces softer and easier to pass 63. improve the ability to pass flatus 64. exert osmotic pressure that pulls out of interstitial spaces. choosing a time in the client’s pattern to initiate defection-control measures Mosby items and derived items © 2009. sitting position b. lubricant) 55. frequent mouth care 68. client sets regular defecation habits 49. incorporating principles of gerontologic nursing when providing bowel training programs for older adults 70. and stimulation of the vagus nerve.Study Guide Answer Key 147 i. bowel incontinence 43.

to apply manual pressure with the hands over the abdomen. Reabsorption in the small intestine is very efficient. Larry also tells Javier that he “just doesn’t feel good. assisting the client to the toilet at the designated time 74. no water. See Box 46-5 for rationale. 80. will voice relief from constipation. and adult stool is brown. . and corn for dinner. able to have regular. soup for lunch. The goals will be accomplished by Javier by encouraging fluid intake of appropriate fluids.. 81. avoiding medications that increase constipation 75. The nurse asks Larry about his recent bowel elimination patterns over the last 5 days. a home care nurse. 2. On palpation. and chicken. Larry lives 20 miles from town. 79. an affiliate of Elsevier Inc. providing privacy and setting a time limit for defecation 76. 82. 1. correct volume for a school-aged child 83. giving stool softeners orally every day or a cathartic at least a half an hour before the selected defecation time 72. and toast for breaksfast. raising the HOB assists the client to a more normal sitting position. 2005 by Mosby. instruct the client to lean forward at the hip when on the toilet. left lower quadrant is tender and firm.Study Guide Answer Key 148 71. fruit juice. but he will drink a Coke. Mosby items and derived items © 2009. In a supine position.” His past history includes a trauma abdominal surgery repair after being struck by a bull’s horns last summer. 4. Diet included eggs. it is impossible to contract the muscles used during defecation. and providing privacy when defecating. and to bear down but not strain to stimulate colon emptying 77. Inc. encouraging activity within the limits of client’s mobility regimen. rice. is visiting Larry at his home on one of the local cattle ranches. offering a hot drink or fruit juice before the defecation time 73. The nurse asks about any nausea or vomiting. 3. The nurse reviews dietary intake over last day. and will identify measures that will prevent constipation. providing stool softeners or laxatives as ordered. “It really hurts. Larry states. adding 20g/day of wheat bran to diet. pain-free defecation of soft. which Larry denies. bacon. He drinks about six cups of coffee each day. formed stool 78. enhancing that ability to defecate. 1. from being thrown from a horse. Javier. Larry tells Javier that he has not had a bowel movement since he left the hospital 4 days ago and that he feels like his abdomen is tight and sore. The nurse then auscultates client’s abdomen and finds decreased bowel sounds throughout all four abdominal quadrants. He is 22 years old and had surgery 6 days ago for repair of a badly broken right leg. and water.” The goals are that the client will establish normal defecation. An infant’s stool is yellow.

common in infants 27.or C-shaped spinal column with vertebral rotation. h 10. adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum) f. m 22. I 25. which is normal until 2 to 3 years of age h. o 19. in which sternocleidomastoid muscle is contracted b. balance. a. pigeon-toes: Internal rotation of forefoot or entire foot. unequal heights of hips and shoulders e. Inc. c 2. scoliosis: Lateral S. s 12. bowlegs: One or both legs bent outward at knee. occasionally. q 17. congenital hip dysplasia: Hip instability with limited abduction of hips and. and fractures Mosby items and derived items © 2009.. contusions. torticollis: Inclining of head to affected side. a 7. sprains. an affiliate of Elsevier Inc. n 16. e 3. e 11. l 14. b 6. b 20. p 23. f 5. impaired body alignment. f 13. g 9. k 15. c 18. 2005 by Mosby. d 4. d 26. r 8. . knock knee: Legs curved inward so that knees come together as person walks g. bruises. clubfoot: 95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus) i. lordosis: Exaggeration of anterior convex curve of lumbar spine c. j 21. and mobility 28. a 24.Study Guide Answer Key Chapter 47: Mobility and Immobility 149 1. footdrop: Inability to dorsiflex and invert foot because of peroneal nerve damage j. kyphosis: Increased convexity in curvature of thoracic spine d.

collapse of alveoli b. impaired skin integrity 47. osteoporosis e. risk for injury 46. a. a. prevention of work-related injury b. reduce orthostatic hypotension – early mobilization b. to the person’s ability to move about freely 30. a. skin color and temperature return to normal baseline within 20 minutes of position change b. Allowing ill or debilitated clients to rest d. a. identifies trauma. particular manner or style of walking 41.. is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal. vitamin B and C supplements 53. risk factors 43. urinary stasis (renal pelvis fills before urine enters the ureters) b. CPT c. fibrin. increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP b. joint contractures f. impaired joint mobility d. an affiliate of Elsevier Inc. ensure intake of 2000 mL of fluid per day 54. a. and maintaining fitness 42. decreases the metabolic rate. changes position at least every 2 hours 51. sensory alterations c. disturbed sleep pattern 48. exercise d. a high caloric diet b. to the lower back c. and muscle mass and decreased stability and balance b. alters the metabolism of CHO. a. emotional and behavioral responses b. 2005 by Mosby. Allowing exhausted clients the opportunity for uninterrupted rest 32. . footdrop 36. impaired calcium metabolism c. perform active and passive ROM exercises b. a. impaired urinary elimination 50. accumulation of platelets. physical activity for conditioning the body. and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel 35. prevent urinary stasis and calculi and infections Mosby items and derived items © 2009. and TEDs) 55. well-hydrated b. and causes GI disturbances 33.Study Guide Answer Key 150 29. CPM machines 56. a. changes in coping 39. or transverse 40. renal calculi (calcium stones that lodge in the renal pelvis) 37. pressure ulcers (impairment of the skin as a result of prolonged ischemia in tissues) 38. ineffective individual coping 45. SCDs. causes fluid and electrolyte and calcium imbalances. reduce cardiac workload – avoid Valsalva movements c. a. a. fall prevention measures c. Inc. a. early detection of scoliosis 52. learning needs. inflammation of the lung from stasis or pooling of secretions 34. a. a. a. and proteins. improving health. identifies deviations. a. strength. use of therapeutic devices to relieve pressure 57. ineffective airway clearance 44. deep breathe and cough every 1-2 hours b. social isolation 49. positioning and skin care b. prevent thrombus formation – prophylaxis (heparin. Reducing physical activity and the oxygen needs of the body b. clotting factors. frontal. loss of endurance. fats. inability to move freely 31. including postoperative pain or after acute injury. Reducing pain.

4. the client rests on the side with body weight on the dependent hip and shoulder 64.g. client places the weight on the anterior ileum humerus and clavicle 65. due to immobility causing decreased lung elastic recoiling and secretions accumulating in portions of the lungs 70. The nurse will perform a comprehensive assessment of pain including location. Ms. maintain the thumb in slight adduction and in opposition to the fingers c. osteoarthritis) or by the surgery. a. onset/duration. as reported to the nurse. 1. Ms. Adams’ care. and intact. Staples will be removed in 2 days. guided imagery) before. In addition. prevents external rotation of the hips when the client is in supine position b. improve mobility.Study Guide Answer Key 151 58.g. Barbara Adams. Allowing the foot to be dorsiflexed at the ankles prevents this. if possible. during painful activities to decrease pain and Mosby items and derived items © 2009. She has a history of smoking and hypertension. 69. rest on their backs. anticipate change in the client’s status and provide routine and informal socialization b. quality. characteristics. She experiences “aches” and “stiffness” in her joints. frequency. protect the client from the hazards of immobility 68. are activities beyond ADLs that are necessary to be independent in society 66. The nurse will also establish realistic increments for transferring and increasing distance for ambulation because gradually increasing physical activity and setting realistic goals for ambulation encourages activity in older adults. or to perform exercises 60. is rated as a 2 on a scale of 0 to 10 at rest. HOB elevated 45-60 degrees and the knees are slightly elevated 61. Inc. this technique produces a forceful. productive cough without excessive fatigue 72. the nurse instructs Ms. Adams’ pain level. The nurse will be able to determine if pain is being caused by a chronic condition (e. assist in transfer. 4. has been admitted to a skilled care unit for rehabilitation after a total hip replacement (THR) for osteoarthritis.. Adams to use nonpharmacological techniques (e.” She takes pain medication to help her sleep during the night but does not need any during the day. dry. The nurse understands that providing instruction in a quiet environment and giving written instructions in large. especially in her knees and fingers. Adams how her surgery has affected her mobility. Adams’ ability to transfer and finds that she is not able to transfer with help from chair to bed. The wound is clean. need to measure bilateral calf circumference 71.. In order to adjust Ms. Adams about safe transfer and ambulation techniques in an environment with few distractions. the client’s ability to maintain or improve body alignment. an 84-year-old client. allows the client to pull with the upper extremities to raise the trunk off the bed. She states. the nurse will provide written materials that reinforce verbal instructions. A thorough assessment is essential in managing pain in older adults. but it increases to an 8 with activity. she responds that she does not like to get out of bed and that she needs help to get dressed in the morning. easy-toread print enhances learning in the older client. The nurse assesses Ms. footdrop. She is to start physical therapy tomorrow. stimuli to maintain client’s orientation 59. all the body parts are in relation to each other 62. . after and. lies face or chest down 63.. 2005 by Mosby. 3. “I am afraid I am going to fall. When the nurse asks Ms. severity and precipitating factors. a. Always stand on the client’s affected side and support the client by using a gait belt. 67. The nurse can encourage Ms. an affiliate of Elsevier Inc.

Mosby items and derived items © 2009.Study Guide Answer Key 152 increase mobility. Inc. Adams to use adequate pain medication. as aggressive pain management is needed following surgery to decrease the effects of pain and increase mobility in the elderly client.. 2005 by Mosby. . an affiliate of Elsevier Inc. The nurse can also encourage Ms.

the wound heals by granulation tissue formation. 6. Maturation. and epithilialization 16. injured blood vessels constrict and platelets gather to stop bleeding. Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues. may take up to a year. nutrition b. 8. Second most common nosocomial infection. pressure duration c. epithelial proliferation (reproduction). and migration with reestablishment of the epidermal layers 18. begins minutes after the injury and continues for up to 3 days. depending on the organism) 23. infection. Filling of the wound with granulation tissue. wound that is closed by epithelialization with minimal scar formation 15. which indicates wound healing 11. muscle tone and strength Mosby items and derived items © 2009. a. yellow. friction f. new blood vessels as reconstruction progresses. the final stage. Hemostasis. 21. impaired sensory perception b.Study Guide Answer Key Chapter 48: Skin Integrity and Wound Care 1. infection d. black or brown necrotic tissue 13. 17. 5. 19.. wound edges are not approximated. . total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair 25. Braden scale 27. alteration in level of consciousness d. or erosion of a blood vessel by a foreign object (internal or external) 22. pressure intensity b. red. moisture 9. 7. tendon. I – intact skin with non-blanchable redness of a localized area over a bony prominence II – partial-thickness skin loss involving epidermis. 2005 by Mosby. potential effects of impaired mobility. 3. dermis. 153 e f a b d c a. age e. tissue tolerance a. color. risks are poor nutritional status. 2. and odor of wound drainage 14. Inc. Wound is left open for several days. clots form a fibrin matrix. occurs after hemostasis indicates a slipped surgical suture.thickness with tissue loss IV – full-thickness tissue loss with exposed bone. then the wounds are approximated. tissue perfusion c. abnormal. or brown. shear e. contraction of the wound. wound contract. a partial or total separation of wound layers. Norton scale b. an affiliate of Elsevier Inc. a. purulent material drains from the wound (yellow. or muscle 10. or both III – full. impaired mobility c. begins. green. wound healing 28. 4. or white tissue 12. inflammatory response. infection. stringy substance attached to wound bed that is soft. and the resurfacing of the wound by epithelialization 20. describes the amount. moist tissue comprised of new blood vessels. the collagen scar continues to reorganize and gain strength for several months. or obesity 24. passage between 2 organs or between an organ and the outside of the body 26. a dislodged clot. and lasts 3-24 days. consistency.

removal of nonviable necrotic tissue to rid the ulcer of a source of infection.5 cm in depth) c. 2005 by Mosby. impaired tissue integrity 45. sutures. Following each incontinent episode. Consult dietitian for nutritional evaluation. 32. an increase in the caloric intake by 10% 46. a loss of 5% of usual weight. to enable visualization of the wound bed. autolytic c. odor. increases risk for breakdown. malnutrition is a major risk factor. Position client at a 30-degree lateral turn and limit head elevation to 30 degrees. amount. and to provide a clean base necessary for healing 48. acute or chronic pain 40. look for complications and skin coloration 34. mechanical b. and consistency of drainage. control bleeding by applying direct pressure in the wound site with a sterile or clean dressing. for 24-48 hours 50. risk for impaired skin integrity 43. higher percentage of granulation tissue in the wound base b. usually after trauma. with high risk of internal bleeding and infection 33. poor nutrition: Provide adequate nutritional and fluid intake. laceration – sometimes bleeds more profusely depending on depth and location (greater than 5 cm or 2. an affiliate of Elsevier Inc. 37. gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue) Mosby items and derived items © 2009. impaired skin integrity 41. imbalanced nutrition: less than body requirements 39. a. abrasion – is superficial with little bleeding and is considered a partial-thickness wound b. 47. . decreased sensory perception: Assess pressure points for signs of nonblanching reactive hyperemia. puncture – bleeds in relation to the depth and size. ineffective tissue perfusion 44. 31. friction and shear: Reposition client using a drawsheet and lifting off of surface. Adequate pain control and client comfort will increase mobility. or wound closures.Study Guide Answer Key 154 29. impaired physical mobility 42. Provide pressure redistribution surface. risk for infection 38. assist with intake as necessary. sharp/surgical 49. character of the drainage. chemical d. no further skin breakdown in any body location c. weight less than 90% of IDW. Observe the security of the drain and its location with respect to the wound. whether the wound edges are closed. Inc. Continuous exposure of the skin to body fluids. measure the amount. color. Surgical wounds are closed with staples. especially gastric and pancreatic drainage. which depends on the location and the extent of the wound 35.. a. moisture: Assess need for incontinence management. or a decrease of 10 lbs in a brief period 30. which in turn reduces risk. a. 36. Provide a trapeze to facilitate movement. cleanse area with no-rinse perineal cleanser and protect skin with a moisture barrier ointment. the condition of tissue at the wound base. decreased activity/mobility: Establish and post individualized turning schedule.

eliminate wound dead space by loosely filling all cavities with dressing material 54. applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintains a moist environment 60. provides a moist environment. impermeable to bacteria e. minimizing skin trauma and disruption of healing 56. use gentle friction when applying solutions locally to the skin c. assess the size. maintains wound moisture c. assessing the condition of underlying dressings and changing if soiled d. choose a dressing that controls exudates e. and cost f. use a dressing that will continuously provide a moist environment b. soothing and reduces pain b. slowly liquefies necrotic debris d. protects the client from seeing the wound f. a. dressing (moist) needs to be flexible and in contact with all of the wound surface. constant low pressure vacuum to remove and collect drainage 63. can be removed without damaging underlying tissues e. discoloration. a. or exposed wound edges b. Mosby items and derived items © 2009. adheres to undamaged skin b. supporting a wound d. and shape of the wound. assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment 65. assessment of the skin beneath the tape b. provides a moist environment 53. serves as a barrier to external fluids and bacteria but allows the wound surface to breathe c. depth. portable units that connect tubular drains lying within a wound bed and exert a safe. promotes healing by absorbing drainage and debriding a wound d. when irrigating. A person is better able to tolerate short exposure to temperature extremes. a. 62. cleanse in a direction from the least contaminated area to the surrounding skin b.Study Guide Answer Key 155 51. debrides the wound d. do not overlap the wound edges (maceration of the tissue) 59. may be left in place for 3-5 days. selfadhesive and molds well f. prolonged results in reflex vasodilation 66. do not pack tightly (overpacking causes pressure). a. availability. if applied > 1 hour the body reduces blood flow by reflex vasoconstriction to control heat loss from the area b. protects a wound from microorganism contamination b. removing or changing dressings over closed wounds when they become wet or if the client has signs and symptoms of infection 58. reducing or preventing edema e. Never occlude a wound opening with a syringe. 2005 by Mosby. does not adhere to the wound base and is easy to remove 57. an affiliate of Elsevier Inc. cold – diminishes swelling and pain. heat – improves blood flow to an injured part. a. creating pressure over a body part b. promotes thermal insulation of the wound surface g. perform wound care using topical dressings as determined by assessment c. wear sterile gloves d. use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. Inc. absorbs drainage through the use of exudate absorbers b. . securing a splint f. consider caregiver time. inspecting the skin for abrasions. supports or splints the wound site e. choose a dressing that keeps the surrounding skin dry d. permits viewing 55.. a. a. acts as a preventative dressing for high-risk friction areas g. aids in hemostasis c. performing thorough hand hygiene before and after wound care c. immobilizing a body part c. securing dressings 64. a. applying sterile or clean dressings and immobilizing the body part 52. covering exposed wounds or open abrasions with a sterile dressing c. a. a. allow the solution to flow from the least to most contaminated area 61. promotes a moist environment d. edema.

Study Guide Answer Key


67. more sensitive to temperature variations – neck, inner aspect of the wrist and forearm, and perineal region 68. Exposed skin layers are more sensitive to temperature variations. 69. The body responds best to minor temperature adjustments. 70. A person has less tolerance to temperature changes to which a large area of the body is exposed. 71. Tolerance to temperature variations changes with age. 72. physical conditions that reduce the reception or perception of sensory stimuli; tolerance to temperature extremes is high but the risk is also 73. Uneven temperature distribution suggests that the equipment is functioning improperly. 74. very young or older clients: Thinner skin layers in children increase risk of burns. Older clients have reduced sensitivity to pain. open wounds: Subcutaneous and visceral tissues are more sensitive to temperature variations. They also contain no temperature and fewer pain receptors. areas of edema: Reduced sensation to temperature stimuli occurs because of thickening of skin layers from fluid buildup or scar formation. PVD: Body’s extremities are less sensitive to temperature and pain stimuli because of circulatory impairment and local tissue injury. Cold application further compromises blood flow. Confusion: Perception of sensory or painful stimuli is reduced. Spinal cord injury: Alterations in nerve pathways prevent reception of sensory or painful stimuli. Abscessed tooth: Infection is highly localized. Application of heat causes rupture with spread of microorganisms systematically. 75. improve circulation, relieve edema, and promote consolidation of pus and drainage 76. promotes circulation, lessens edema, increases muscle relaxation, and provides a means to debride wounds and apply medicated solutions 77. the pelvic area is immersed in warm fluid 78. used for treating muscle sprains and inflammation and edema 79. disposable hot packs that apply warm, dry heat to an area 80. relieves inflammation and swelling 81. immersing a body part for 20 minutes 82. used for muscle sprain, localized hemorrhage, or hematoma 83. a. Was the etiology of the skin impairment addressed? B. Was wound healing supported by providing the wound base with a moist, protected environment? C. Were issues such as nutrition assessed and a plan of care developed ? 84. 3. is the force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the client and the surface 85. 1. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales . 86. 3. Recommended protein intake for adults is 0.8g/kg; a higher intake of up to 1.8g/kg/day is necessary for healing. 87. 2. See Table 48-9 for choice and rationale for dressings for ulcer stages. 88.

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Study Guide Answer Key


Mrs. Stein, a 76-year-old, is 7 days postoperative for a total hip replacement. She developed redness and oozing of foul-smelling, tan-colored drainage from the hip incision on postoperative day four. Significant medical history includes arthritis and mild hypertension. Because of surgical pain at the incision site, she did not easily transfer from her bed to the chair. Now on day seven, she notes some pain at the incision and complains of a painful, burning sensation in the sacral region. She is continent of urine and stool but continues to “scoot” over to the side of the bed when preparing for bed-to-chair transfers. The nurse obtains an oral temperature and determines that it is elevated. The nurse then asks Ms. Stein how the surgical site limits her mobility, to which she relates that her hip always aches and the pain increases upon movement. She tells the nurse that she prefers to keep the hip immobile to keep the pain level down. Position of comfort is supine, and Mrs. Stein resists position changes. The nurse performs a total body skin assessment, paying special attention to the sacral area. The nurse notes that the client has reactive hyperemia around the sacral area; this area does not blanch upon palpation. There is a partial-thickness ulcer directly over the sacral area. No other areas are open, with the exception of the surgical site. Key areas covered during the assessment included: Sensation, Mobility, Continence, Presence of Wound.

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Study Guide Answer Key Chapter 49: Sensory Alterations


1. c 2. f 3. d 4. b 5. a 6. e 7. c 8. f 9. h 10. j 11. l 12. d 13. I 14. k 15. b 16. g 17. a 18. e 19. a. sensory input (deficit from visual or hearing loss) b. elimination of patterns or meaning from input (exposure to strange environment) c. restrictive environments that produce monotony and boredom 20. cognitive: Reduced capacity to learn; Inability to think or problem-solve; Poor task performance; Disorientation; Bizarre thinking; Increased need for socialization, altered mechanisms of attention affective: Boredom; Restlessness; Increased anxiety; Emotional liability; Panic; Increased need for physical stimulation perceptual: Changes in visual/motor coordination; Reduced color perception; Less tactile accuracy; Ability to perceive size and shape; Changes in spatial and time judgment 21. when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli 22. age, meaningful stimuli, amount of stimuli, social interaction, environmental factors, cultural factors 23. older adults due to normal physiological changes, individuals that live in confined environments, acutely ill clients 24. a. Physical appearance and behavior: Motor activity, posture, facial expression, hygiene b. Cognitive ability: Level of consciousness, abstract reasoning, calculation, attention, judgment; Ability to carry on conversation and ability to read, write, and copy figure; Recent and remote memory c. Emotional stability: Agitation, euphoria, irritability, hopelessness, or wide mood swings; Auditory, visual, or tactile hallucinations, illusions, delusions 25. Sense Assessment Child Behavior Adult Behavior

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sniffing or smelling. failure to respond when touched. Inability to perform developmental tasks related to grasping objects or drawing. greater response to movement than to sound. smiling and nodding of head in approval when someone speaks. increased body odor. 159 Vision Self-stimulation. Ask client to identify colors on color chart or crayons. magazine. decreased attention span. no reflex or purposeful response to sounds.g. Observe client behaviors in a group. Smell Difficult to assess until child is 6 or 7 years old. use of other means of communication such as lip-reading or writing. Assess client’s hearing acuity and history of tinnitus. underreaching or overreaching for objects. sensation of pins and needles. complaints of ringing in ears Clumsiness. avoidance of social interaction with other children Poor coordination. lack of reaction to loud noises. hot distinguish stove. Inspect ear canal for hardened cerumen. an affiliate of Elsevier Inc. hitching (using legs to propel while in sitting position) instead of crawling Frightened when unfamiliar people approach. over reaction or under reaction to painful stimulus. body rocking. positioning of head toward sound. accidental falls Blank looks. difficulty discriminating Failure to react to noxious or strong odor. . arm twirling. increased volume of speech. Ask whether client feels unusual sensations. persistent repositioning of objects. coffee. slow or absent development of speech.g. numbness Unable to identify object placed in hand Hearing Touch Check client’s ability to discriminate between sharp and dull stimuli. Assess whether client repeated injury from handling of harmful is able to objects (e. avoidance of touch. impaired night vision. Inc. including eye rubbing. Observe client performing ADLs. Have client close eyes and identify several nonirritating odors (e.. sharp knife) objects (coin or safety pin) in the hand with eyes closed... failure to be awakened by loud noise.Study Guide Answer Key Technique Ask client to read newspaper. squinting. 2005 by Mosby. or lettering on menu. Observe client conversing with others. increased Mosby items and derived items © 2009.

unlit stairways. an affiliate of Elsevier Inc. . Down syndrome 41. loose area rugs and runners e. especially newborns through preschoolers. extension and phone cords in walkways d. impaired physical mobility 32. The blind or severely visually impaired often touch the boundaries or objects to gain a sense of their surroundings. prenatal infection c. noxious odors Inability to tell whether food is salty or sweet. chronic ear infection e. lack of railings j.. impaired adjustment 29. lemon. for congenital blindness and visual impairment caused by refractive error and strabismus 39. excessive use of seasoning and sugar. impaired verbal communication 30. cracked walkways leading to doors b.g. absence of smoke detectors i. screening for rubella or syphilis in women who are considering pregnancy b. disorientation. accidental falls 26. a. bathrooms without shower or tub grab bars f. demonstrate technique for cleansing hearing aid within 1 week c. social isolation 36. risk for injury 31. salt). use communication techniques for improved reception of messages b. a. weight change Clumsiness. unmarked water faucets g. low birth weight d. (Have client drink or sip water and wait 1 minute between each taste. sugar. family history b. Senses Physiological Change Interventions Mosby items and derived items © 2009.. accidental falls Taste Position sense Clumsiness. advocate adequate prenatal care to prevent premature birth c. possible ingestion of strangetasting things 160 sensitivity to odors Change in appetite. self-report improved hearing acuity 38. periodic screening of children. uneven. cluttered floors k. Ask client to sample and distinguish different tastes (e. (sensory) the inability to understand written or spoken language 28. kitchen equipment with hard-to-read settings 27. a. Inc. use proper communication skills to send and receive messages d. doormats with slippery backing c. (motor) inability to name common objects or to express simple ideas in words or writing b. self-care deficit 33. 2005 by Mosby. refractive error such as nearsightedness 40. complaints about taste of food. disturbed thought processes 37. disturbed sensory perception 35.Study Guide Answer Key vanilla). a. a.) Observe client in the environment. situational low self-esteem 34. disorientation. slippery bathroom floors h.

Study Guide Answer Key Vision Presbyopia: A gradual decline in the ability of the lens to accommodate or to focus on close objects. Cataract: Cloudy or opaque areas in part of the lens or Encourage client to discuss what goals are important to the entire lens that him or her. Complete a thorough health history and physical assessment to identify health problems that complicate life with visual impairment. without pain. Macular degeneration: Condition in which the Mosby items and derived items © 2009. self-care. tears. 161 Assess for the presence of social networks and supportive relationships. an affiliate of Elsevier Inc. resulting in peripheral visual loss. decreased visual acuity with difficulty adapting to darkness. denial. anger. . and a halo effect around lights. Individual is unable to see near objects clearly.g. 2005 by Mosby. interfere with passage of Provide factual information light through the lens. Cataracts usually develop Assist with identification of creative strategies to promote gradually. redness. burning. cope with the loss of vision Dry eyes: Result when tear and encourage expression of glands produce too few feelings (e.. resulting in decreased vision or vision loss due to hemorrhage and macular edema.. about the disease and answer causing problems with questions truthfully. Glaucoma: A slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve. or even reduced vision. glare and blurred vision. hopelessness). resulting in itching. Inc. or tearing in the Explore the client’s ability to eye. if left untreated. Diabetic retinopathy: Pathological changes occur in the blood vessels of the retina.

use caution when administering drugs that are ototoxic. Advise pregnant women to seek early prenatal care and to undergo testing for syphilis and rubella. The screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) is a 5-minute. First signs include blurring of reading matter. Cerumen accumulation: Buildup of earwax in the external auditory canal. differently Mosby items and derived items © 2009.. . Good oral hygiene keeps the taste buds well hydrated. 10-item questionnaire developed to assess how the individual perceives the social and emotional effects of hearing loss. Cerumen becomes hard and collects in the canal and causes a conduction deafness. 162 Taste and smell Xerostomia: Decrease in salivary production that leads to thicker mucus Irrigation of the canal with two to three ounces of tepid water in a 60ml syringe (see Chapter 39) will remove cerumen and significantly improve the client’s hearing ability.. Hearing Presbycusis: A common progressive hearing disorder in older adults. schools. Well-seasoned. and measles). and community clinics need to reinforce the importance of early and timely immunization. Nurses who work in physicians’ offices. Prevention involves regular immunization of children against diseases capable of causing hearing loss (e. and distortion of vertical lines.Study Guide Answer Key macula (specialized portion of the retina responsible for central vision) loses its ability to function efficiently. In all populations.g. an affiliate of Elsevier Inc. distortion or loss of central vision. rubella. 2005 by Mosby. mumps. Inc.

g. Older persons need to chew food thoroughly to allow more food to contact remaining taste buds.. soiled dressings) will also improve the quality of a client’s environment. a back rub. Clients with reduced tactile sensation usually have the impairment over a limited portion of their bodies. mild room deodorizers. Turning and Touch With aging. an affiliate of Elsevier Inc. Mosby items and derived items © 2009. . because these actions make it difficult to identify tastes. there are decreased skin receptors. You improve smell by strengthening pleasant olfactory stimulation. Stimulation of the sense of smell with aromas such as brewed coffee. Improvement in taste perception improves food intake and appetite as well. Providing touch therapy stimulates existing function. cooked garlic. and sachets. If the client is willing to be touched.. and touching of the arms or shoulders are ways of increasing tactile contact. and baked bread heightens taste sensation. Always ask the client what foods are most appealing.Study Guide Answer Key and a dry mouth. bedpans. When sensation is reduced. The client needs to avoid blending or mixing foods. Flavored vinegar or lemon juice adds tartness to food. a firm pressure is often necessary for the client to feel the nurse’s hand. Often interferes with the ability to eat and leads to appetite and nutritional problems. 163 textured food eaten separately heightens taste perception. 2005 by Mosby. Make a client’s environment more pleasant with smells such as cologne. fragrant flowers. The removal of unpleasant odors (e. Inc. hair brushing and combing.

a the tube prevents a client communication board or a from speaking. family. Give the client time to write messages. Give the client time to understand. because these clients become easily fatigued. . clients with aphasia – Listen to the client and wait for the client to communicate. completely alert and able to oftentimes an endotracheal hear and see the nurse tube is inserted into the normally.. it is important to use touch by holding the client’s hands and keeping them warm and dry. or word cards so that the client can point.g. 2005 by Mosby. When performing invasive procedures. be calm and patient. do not pressure or tire the client. Offer a pad and pencil or Magic Slate for the client to write messages. If a client is overly sensitive to tactile stimuli (hyperesthesia). Offer pictures or a communication board so that the client can point. objects. Do not shout or speak loudly (hearing loss is not the problem). Be sure the client knows that you Mosby items and derived items © 2009. minimize irritating stimuli. Speak of things familiar and of interest to the client. use simple. In hospitalized clients The client is sometimes needing an artificial airway. Avoid patronizing and childish phrases. and friends. Provide an artificial voice box (vibrator) for the client with a laryngectomy to use to speak. clients with a hearing impairment –Get the client’s attention. The placement of techniques (e. short questions and facial gestures to give additional clues. Do not approach a client from behind. If the client has problems speaking. laptop computer) to foster and strengthen the client’s interactions with health care personnel. Inc. an affiliate of Elsevier Inc.. If the client has problems with comprehension. ask questions that require simple yes or no answers or blinking of the eyes. Keeping bed linens loose to minimize direct contact with the client and protecting the skin from exposure to irritants are helpful measures. Do not shout or speak loudly.Study Guide Answer Key 164 repositioning will also improve the quality of tactile sensation. clients with an artificial airway – Use pictures. larynx into the upper Use creative communication bronchus. Giving the client oropharynx and down time to convey any needs or through the vocal cords of the requests is very important. Do not startle the client when entering the room. Trachea 42.

g. rephrase rather than repeat the conversation. Keep hands away from mouth. . Do not restrict a deaf client’s hands. If you need to raise your voice. also need to evaluate the integrity of the sensory organs and the client’s ability to perceive stimuli 46.Study Guide Answer Key 165 wish to speak. rugs or other floor surfaces. 2005 by Mosby. cracked walkways. make sure it is in place and working. Loud sounds are usually higher pitched and often impede hearing by accentuating vowel sounds and concealing consonants. 4. Speak with your hands. c. 45. Use a normal tone of voice and inflections of speech. the nature of a client’s alterations influence how the nurse would evaluate the outcome of care. and your eyes. frequent repositioning 44.. uneven. Do not shout. Be sure your face and lips are illuminated to promote lip-reading. h. motor type of aphasia 50. 4. Assist older adults in keeping in contact with people important to them. Priorities need to be set in regard to the type and extent of the sensory alteration. control extraneous noise d. Use visible expressions. the presence or absence of meaningful stimuli (constant TV) influences alertness and the ability to participate in care 48. note physical boundaries b. Use written information to enhance the spoken word. embracing a shoulder) to convey caring. Never have IV lines in both of the client’s hands if the preferred method of communication is sign language. Do not speak with something in your mouth. Inc. e. Following the recommendation of her health care provider. or smoking while speaking. Be sure that clients keep eye glasses clean so that they are able to see your gestures and face. Bring a pet that is easy to care for into the home. Avoid speaking from another room or while walking away. 3. and safety is always a top priority. sighted guide. a. Older adults often take longer to process verbal messages. extension or phone cords in the main route of walking Mosby items and derived items © 2009. Avoid eating. address the client by name. Link a person with religious organizations attuned to the social needs of older adults. slippery doormats. 1. your face. Speak slowly and articulate clearly. If the client wears a hearing aid. safety measures – help with ambulation. due to sensory deprivation related to restrictive environment of the hospital 47. Talk toward the client’s best or normal ear. g. She has asked the nurse to speak with the heart-failure support group regarding agerelated visual changes. orientation to the environment – name tags are visible. b. as well as signs and symptoms that may indicate problems. Help recommend alterations in living arrangements if physical isolation is a factor. control sensory stimuli – prevent overload by organizing client’s care with periods of rest. Some of the selected strategies to assist Judy in remaining functional in her home would include removing any potential safety hazards (e.. f. a. chewing. she regularly attends a heart-failure support group. Face the client and stand or sit on the same level. an affiliate of Elsevier Inc. there needs to be a change in the interventions or an alteration in the client’s environment. communication – depending on the type of aphasia (Box 49-9) c. When you are not understood. d. Judy was released from the hospital in good health one week after admission. if the expected outcomes have not been achieved. Use physical contact (holding a hand. Help obtain information about mutual help groups. speak in lower tones. Arrange for security escort services as needed. explain to the client any transfers. Spend time with a person in silence or conversation. 49. 43.

an affiliate of Elsevier Inc. and community agencies for assistance.. The nurse will also involve family in assisting Judy to adjust to her limitations and referring Judy to the appropriate health care. kitchen equipment with hard-to-read settings). Inc. professional. absence of smoke detectors. bathrooms without shower or tub grab-bars. . Mosby items and derived items © 2009. 2005 by Mosby. The nurse will assist Judy in planning transportation to and from social activities and her support group. clutter in the home. poorly lit areas.Study Guide Answer Key 166 traffic.

General anesthetic agents depress cardiac function. Abuse of street drugs: Persons abusing drugs sometimes have underlying disease (HIV/hepatitis). pneumonia and spasm of laryngeal muscles). preoperative (before). f 12. poor tolerance to anesthesia b. upper respiratory infection: Increases risk of respiratory complications during anesthesia (e. Clients will desaturate as revealed by drop in O2 saturation by pulse oximetry. I 9. a. b 10. 2005 by Mosby. Inc. fever: Predisposes client to fluid and electrolyte imbalances and may indicate underlying infection. heart disease: Stress of surgery causes increased demands on myocardium to maintain cardiac output. a 14. anesthetic drugs that metabolize rapidly with few after-effects allow for shorter operative times and faster recovery time b. . liver disease: Alters metabolism and elimination of drugs administered during surgery and impairs wound healing and clotting time because of alterations in protein metabolism. and costs 3. hospitalization.g. d 4. thrombocytopenia: Increase risk of hemorrhaging during and after surgery.. e 15.. l 11. Anesthetic agents reduce respiratory function. multiple organ failure Mosby items and derived items © 2009. intraoperative (during). emphysema: Reduces client’s means to compensate for acid-base alterations (see Chapter 41). Increased doses of analgesics are sometimes necessary to achieve postoperative pain control. j 6. k 13. an affiliate of Elsevier Inc. use of laparoscopic procedures instead of traditional surgical procedures decreases the length of surgery. a. g 8. poor wound healing f. postoperative (after surgery) 2. 16.Study Guide Answer Key Chapter 50: Care of Surgical Clients 167 1. offers cost savings by eliminating the need for hospital stay c. AIDS: Increases risk of infection and delayed wound healing after surgery. negative nitrogen balance from the lack of protein c. obstructive sleep apnea: Administration of opioids increases risk of airway obstruction postoperatively. infection e. h 5. which affects healing. increasing risk for severe hypoventilation. delayed clotting mechanisms d. c 7. Chronic pain: Regular use of pain medications often results in higher tolerance. diabetes mellitus: Increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment (Furnary and others 2003). Stress of surgery often causes increases in blood glucose levels.

exposure of body parts during procedure. can reduce cardiac contractility and impair cardiac conduction during anesthesia. a difficulty resuming activity after surgery b. phenytoin [Dilantin®] and phenobarbital) alters metabolism of anesthetic agents. aminoglycosides (gentamycin. tobramycin. Inc. cardiovascular system: • Degenerative change in myocardium and valves: Reduced cardiac reserve • Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation to heart: Alterations predispose client to postoperative hemorrhage and rise in systolic and diastolic blood pressure. thickened arterial walls: Predispose client to clot formation in lower extremities integumentary system: • Decreased subcutaneous tissue and increased fragility of skin: Prone to pressure ulcers and skin tears pulmonary system: • Rib cage stiffened and reduced in size renal system: Reduced vital capacity • Reduced range of movement in diaphragm: Greater residual capacity (volume of air is left in lung after normal breath) increases.. • Increase in calcium and cholesterol deposits within small arteries. beta blockers such as metoprolol [Lopressor®]). neomycin) may cause mild respiratory depression from depressed neuromuscular transmission. reducing amount of new air brought into lungs with each inspiration • Stiffened lung tissue and enlarged air spaces: Alteration reduces blood oxygenation. neurological system: • Sensory losses.g. • Change in total amounts of body potassium and water volume: Greater risk for fluid or electrolyte imbalance occurs.. Aspirin is a commonly used medication that alters clotting mechanisms. . Mosby items and derived items © 2009. Discontinued at least 48 hours before surgery. including reduced tactile sense and increased pain tolerance: Decreased ability to respond to early warning signs of surgical complications • Decreased reaction time: Confusion after anesthesia metabolic system: • Lower basal metabolic rate: Reduced total oxygen consumption • Reduced number of red blood cells and hemoglobin levels: Ability to carry adequate oxygen to tissues is reduced. Anticonvulsants: Long-term use of certain anticonvulsants (e.Study Guide Answer Key 168 17. If taken within 2 weeks before surgery. Antidysrhythmias: Antidysrhythmics (for example. such as warfarin (Coumadin®).. Antibiotics: Antibiotics potentiate (enhance action) of anesthetic agents. IV fluids. alter normal clotting factors and thus increase risk of hemorrhaging. 2005 by Mosby. an affiliate of Elsevier Inc. poor wound healing and wound infection d. Anticoagulants: Anticoagulants. reduced ventilatory and cardiac function c. • Impaired thermoregulatory mechanisms: Cold operating rooms. medications 19. high risk of dehiscence and evisceration 18.

dosages are often temporarily increased. past stress management and behaviors utilized. NSAIDs: NSAIDs (for example. corticosteroids. Elevated level can indicate renal failure. c. assess for body image alterations that clients perceive will result. a. age. hypotension. cause adrenal atrophy. family expectations for pain management following surgery b. and impaired circulation.. increasing susceptibility to postoperative bleeding. 20. IV fluid replacement may be indicated preoperatively. Serum electrolytes: Peripheral venous sample of blood may reveal significant fluid and electrolyte imbalances preoperatively. thorax and lungs e. and coping resources 25. interact with anesthetic agents to cause bradycardia. malnourishment also leads to delayed wound healing 21. taking into consideration culture. loss of body function 24.Study Guide Answer Key 169 Antihypertensives: Antihypertensives. activated partial thromboplastin time (APTT). greater risk for pulmonary complication due to increased amount and thickness of mucous secretions in the lungs b. such as prednisone. K. Attention is given to Na. Before and during surgery. alteration in body function or concern over mutilation. past experiences and interventions used 22. integument d. heart and vascular system f. abdomen g. have client identify personal strengths and weaknesses. Insulin: Diabetic clients’ need for insulin changes after surgery. head and neck c. and potential for oxygenation problems. Surgeon may order blood replacement. ibuprofen) inhibit platelet aggregation and prolong bleeding time. Herbal therapies: These herbal therapies have the ability to affect platelet activity and increase susceptibility to postoperative bleeding. Ginseng is reported to increase hypoglycemia with insulin therapy. of feelings and self-concept reveals whether the client is able to cope with the stress of surgery. Reveals clients at risk for bleeding tendencies and thrombus formation. . predisposes the client to adverse reactions to anesthetic agents and cross-tolerance to anesthetic agents. such as beta blockers and calcium channel blockers. poor self-concept hinders the ability to adapt to the stress of surgery and aggravates feelings of guilt or inadequacy 23. assesses renal function. Stress response and intravenous (IV) administration of glucose solutions often increase dosage requirements after surgery. perceived tolerance to pain c. Mosby items and derived items © 2009. self-concept. a. International Normalized Ratio (INR). by-product of muscle metabolism. Diuretics: Diuretics such as furosemide (Lasix®) potentiate electrolyte imbalances (particularly potassium) after surgery. and platelet counts reveal clotting ability of blood. which reduces the body’s ability to withstand stress. general survey b. and self-esteem. They inhibit synthesis and storage of norepinephrine in sympathetic nerve endings. removal of body parts often leaves permanent disfigurement. b. Corticosteroids: With prolonged use. Serum creatinine: Ability of kidneys to excrete creatinine. and Cl levels. d. a. Decreased nutritional intake often decreases dosage requirements. CBC: Peripheral venous sample of blood may reveal infection. low blood volume. neurological status 26. an affiliate of Elsevier Inc. Coagulation studies: Prothrombin time (PT). 2005 by Mosby. a. Inc.

expected results and alternative treatments 48. or bleeding eruptions. a. disturbed sleep pattern 45. Preoperative IV fluid replacement is often necessary. vital signs g. 2005 by Mosby. nausea 41. risk for imbalanced body temperature 32. removal of prostheses d. disturbed body image 31. hair and cosmetics c. hygiene b. washcloth. BUN: Ability of kidneys to excrete urea and nitrogen indicates renal function. a. glucose: Finger stick or peripheral blood sample. an affiliate of Elsevier Inc. eliminating the wrong site and wrong procedure surgery 51. latex sensitivity/allergy k. a. administering preoperative medications j. a. maintenance of normal fluid and electrolyte balance b. safeguarding valuables e. deficient knowledge 39.. sphygmomanometer. postoperative activity resumption g. a. the postoperative unit and location of the family during surgery and recovery d. ineffective airway clearance 28. describes surgical procedures and postoperative treatment f. BUN becomes elevated if client is dehydrated. range from urticaria and flat or raised red patches to vesicular. and promotes recovery 47. risk for latex allergy response 29. f. risk for perioperative-positioning injury 38. reduction of risk of surgical wound infection c. the steps involved. 27. risk for deficient fluid volume 36. oxygen equipment Mosby items and derived items © 2009. preparing the bowel and bladder f. performing special procedures i. Clients often require treatment of low or high levels preoperatively and postoperatively. reasons for preoperative instructions and exercises b. improves lung function. documentation h. anxiety 30. and thermometer b. suction equipment g. discusses anticipated postoperative monitoring and therapies e. risks. acute pain 42. assists with return of bowel function. 52. verbalizes painrelief measures 49. stethoscope. risk for infection 37. promotion of rest and comfort 50. promotion of blood flow to prevent leg clots as reason for postoperative leg exercises and ambulation c. towel and tissues e. delayed surgical recovery 46. impaired physical mobility 40. ineffective breathing pattern 33. scaling. the time of surgery c. prevention of lung congestion and pneumonia as reasons for deep breathing and coughing exercises and incentive spirometer b. emesis basin c. prevention of bowel and bladder incontinence d.Study Guide Answer Key 170 e. ineffective coping 34. rhinitis and rhinorrhea are also common. fear 35. understands the need for a procedure. impaired skin integrity 44. IV pole f. . clean gown d. Inc. powerlessness 43.

fluid and food allowed f. cyanosis. evaluating the care. minimal pain and nausea. skin mottling.Study Guide Answer Key 171 and oximetry monitor h. and muscular rigidity 67. equipment use 56. surgery c. secretions in the pharynx. a. basing always on the frequency of assessment on the client’s current condition 64. history of OSA b. bed raised to stretcher height to accommodate transfer 53. is oriented to self and the hospital b. recovery period b. will be free of burns at the grounding pad 55. and neurological status and on managing pain 62. and movement of all extremities c. postoperative convalescence (both vary depending on outpatient versus inpatient ) 61. results in loss of sensation in an area of the body via spinal. establishing and implementing the intraoperative plan of care. maintenance. involves the loss of sensation at the desired site. circulatory. a. accumulation of gas b. daily weights 68. review of the preoperative assessment. papillary and gag reflexes. Given by IV and inhalation routes through 3 phases (induction. a. maintaining airway. tachypnea. resumption of preoperative medications e. . a. a. monitor can compare lab values c. unstable blood pressure. every 15 minutes. Inc. assess the hydration status and monitor cardiac and neurological function b. result from inappropriate positioning or restraining that injures skin layers or from a clotting disorder c. frequency of VS assessments b. bronchial tree. positioning d. will have intact skin and show no signs of redness b. bed pads to protect j. orientation to surroundings. and dressings Mosby items and derived items © 2009. absence of complications. pulses. quiet client who does not recall the surgical procedure 57. controlled wound drainage. adequate output. routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness 60. irrigations. lab tests and x-ray studies j special directions related to drains. intake and output i. good ventilatory function and oxygenation status. then hourly for 4 hours then every 4 hours. temperature control. an affiliate of Elsevier Inc. or a peripheral nerve block with no loss of consciousness 58. a. a. heart rate and rhythm. extremity strength 69. maintains a sterile field during the surgical procedure and assists with supplies 54. 2005 by Mosby. maintain patency of IV lines d. a. respiratory. vital sign stability. or trachea d. tachycardia. indicates a drug sensitivity or allergy b. hypercabia. and fluid and electrolyte balance 63. resulting in an immobile. and the color and temperature of the nail beds and skin 66. anesthesia b. level of activity g. types of IV fluids and rates c. extra pillows for positioning i. weak pharyngeal/laryngeal muscle tone from anesthetics c. internal bleeding (late) c.. BP and capillary refill. and providing for continuity of care postoperatively b. client’s sensations along dermatomes d. common for minor procedures 59. and emergence). PVCs. a. develops a paralytic ileus 71. hand grips. may indicate that a electrical cautery grounding pad was incorrectly placed 70. positions h. a. epidural. record accurately the I & O. postoperative medications d. subglottic edema 65.

Signs and symptoms are same as for hemorrhage. c.Study Guide Answer Key 172 72. tachycardia or bradycardia. high or low blood pressure. Signs and symptoms include hypotension. dyspnea. f. fever. Inc. Signs and symptoms include fever. Cause: Anesthetics and analgesics depress respirations. It may involve one or several lobes of lung. confusion. and respirations are even and unlabored c. an affiliate of Elsevier Inc. 79. a. which causes most cases of pneumonia. Increased retention of mucus with impaired ventilation occurs because of pain or poor positioning. productive cough. Signs and symptoms include restlessness. Cause: Slipping of suture or dislodged clot at incisional site. and immobilized position prevent full lung expansion. Development in lower dependent lobes of lung is common in immobilized surgical client. temperature returns to baseline and remains stable d. pneumonia: Inflammation of alveoli. weak and rapid pulse. b.. cyanosis. 82. Initiate orotracheal ornasotracheal suction for inability to cough. Turn patient on their sides every 1-2 hours and to sit when possible. dyspnea. Anesthesia. analgesia. diaphoresis. restlessness. There is greater risk in clients with upper abdominal surgery who have pain during inspiration and repress deep breathing. 81. and productive cough. Keep the client comfortable. and cyanosis. Mosby items and derived items © 2009. Clients with OSA are at increased risk for hypoxemia. Cause: Inadequate lung expansion. Cause: Poor lung expansion with retained secretions or aspirated secretions. Cause: In surgical client. use incentive spirometer for maximum inspiration 76. 2005 by Mosby. chest pain. chills. airway is patent. encourage diaphragmatic breathing exercises every hour 74. administer CPAP or NIPPV to clients who use this modality at home 75. a. 80. Provide oral hygiene. VS return to preoperative baseline b. purulent mucus. and drop in blood pressure. Signs and symptoms include elevated respiratory rate. cool and clammy skin. hypoxemia: Inadequate concentration of oxygen in arterial blood. Clients with coagulation disorders are at greater risk. hemorrhage usually causes hypovolemic shock. Cause: Same factors lead to formation of thrombus or embolus. Signs and symptoms include dyspnea. sudden chest pain. e. tachycardia. hypovolemic shock: Inadequate perfusion of tissues and cells from loss of circulatory fluid volume. atelectasis: Collapse of alveoli with retained mucous secretions. hemorrhage: Loss of large amount of blood externally or internally in short period of time. crackles auscultated over involved lobes of lungs. pulmonary embolism: Embolus blocking pulmonary arterial blood flow to one or more lobes of lung. and dyspnea. 78. Administer oxygen and monitor saturation. and reduced urine output. Encourage coughing exercises every 32 hours and maintain pain control. Immobilized surgical client with preexisting circulatory or coagulation disorders is at risk. . early ambulation 77. d. rapid breathing. Common resident bacterium in respiratory tract is Diplococcus pneumoniae. returns to previous level of activity 73. 83. fluid and electrolyte levels remain balanced e.

red.. o. and leukocyte esterase positive on urinalysis. influx of air for procedure causes distention and pain up to shoulders. k. or immobilization. severe pain. Vein feels hard. Signs and symptoms include dysuria. itching. an affiliate of Elsevier Inc. i. Clients with pelvic and abdominal cancer or traumatic injuries to the pelvis or lower extremities are at high risk for thrombus formation. 2005 by Mosby. brain. Signs and symptoms include increased abdominal girth. Cause: Abdominal distention. During laparoscopic surgeries. Inc. Client complains of gagging or feeling full or sick to stomach. bowel manipulation. Symptoms include localized tenderness along distribution of the venous system. client complaints of fullness and “gas pains. thrombophlebitis: Inflammation of vein often accompanied by clot formation. Signs and symptoms include inability to void. swollen calf or thigh. possible fever. and bladder distention. pelvis. restlessness. Cause: Effects of anesthesia and narcotic analgesics. Cause: Venous stasis (see discussion of thrombophlebitis) and vessel trauma. Infection usually appears 3-6 days after surgery.Study Guide Answer Key 173 g. fever and chills. Veins in legs are most commonly affected. and initiation of gag reflex. urinary tract infection: An infection of the urinary tract as a result of bacterial or yeast contamination. Venous injury is common after surgery of hips and legs.” Cause: Slowed peristalsis from anesthesia. thrombus: Formation of clot attached to interior wall of a vein or artery. and tender skin around incision. wound infection: An invasion of deep or superficial wound tissues by pathogenic microorganisms. Cause: Thrombi form from increased coagulability of blood (e. which can occlude the vessel lumen. medications. polycythemia and use of birth control pills containing estrogen). or chemical imbalance associated with decreased peristalsis. neurogenic. h. Cause: Most frequently a result of catheterization of the bladder. and major vessels. Common in initial hours after abdominal surgery. nausea and vomiting: Symptoms of improper gastric emptying or chemical stimulation of vomiting center. commonly lungs. paralytic ileus: Nonmechanical obstruction of the bowel caused by physiological. Cause: Prolonged sitting or immobilization aggravates venous stasis. Local manipulation of tissues surrounding bladder and edema interfere with bladder tone. n. l. or mesentery. embolus: Piece of thrombus that has dislodged and circulates in bloodstream until it lodges in another vessel. Poor positioning of client impairs voiding reflexes. heart. cordlike.g. and sensitive to touch. abdominal distention: Retention of air within intestines and abdominal cavity during gastrointestinal surgery. Cause: Infection is Mosby items and derived items © 2009. j. and decrease in pulse below location of thrombus (if arterial). WBCs. abdomen. . pitting edema in symptomatic leg and collateral superficial veins. Cause: Handling of intestines during surgery leads to loss of peristalsis for a few hours to several days. urinary retention: Involuntary accumulation of urine in bladder as result of loss of muscle tone. It appears 6-8 hours after surgery. Trauma to vessel wall and hypercoagulability of blood increase risk of vessel inflammation. Signs and symptoms include swelling and inflammation of involved site and aching or cramping pain.. tympanic percussion over abdominal quadrants. purulent material exiting from drains or from separated wound edges. m. calf swelling >3 cm compared to asymptomatic leg. abdominal pain. cloudy urine. signs and symptoms include warm. eating or drinking before peristalsis returns. fear.

a. fiber supplements. pleasant environment e. anxiety. Cause: Client with dehiscence is at risk for developing evisceration. 3. not always a sign of hypothermia but rather a side effect of certain anesthetic agents Mosby items and derived items © 2009. provide adequate fluid intake orally or IV 90. provide privacy with dressing changes or inspection of the wound b. 1. assume normal positioning during voiding c.. positioning. resulting in edema and delayed healing. Incidence usually occurs 6-8 days after surgery. prevent drainage devices from overflowing d.concept 94. drainage tubes. promote ambulation and exercise c. skin breakdown: Result of pressure or shearing forces. or positioning. light diet. a.Study Guide Answer Key 174 caused by poor aseptic technique or contaminated wound or surgical site before surgical exploration. a. offer opportunities for the client to discuss fears or concerns f. For example. apply elastic antiembolism stockings or pneumatic compression stockings 86. r. . s. poor circulation to tissues. or the inability to obtain po fluids. old age. stool softeners f. That is a medical decision and the responsibility of the provider. full liquids. 97. p. oral hygiene) e. Signs and symptoms include increased drainage and appearance of underlying tissues. Cause: Prolonged periods on the OR table and in the bed postoperatively lead to pressure breakdown. Cause: Malnutrition. encourage to perform leg exercises 85. This usually occurs 6-8 days after surgery. and unusual strain on suture line from coughing or positioning cause dehiscence. 2. maintain client’s hygiene c. incision area. tight dressing or casts. 84. muscular strains caused by positioning 91. administer anticoagulant drugs as ordered 89. obesity. maintain and adequate fluid intake d. 96. an affiliate of Elsevier Inc. with a bowel perforation. 1. wound dehiscence: Separation of wound edges at suture line. stimulate the client’s appetite (remove noxious odors. monitor I & O 93. Inc. assess for bladder distention d. intractable pain: Pain that is not amenable to analgesics and pain-alleviating interventions. avoid positioning client in a manner that interrupts blood flow to the extremities 88. check frequently for the need to void c. usual diet) b. q. desired foods. wound evisceration: Protrusion of internal organs and tissues through incision. fluid overload. preoperative radiation to surgical site. 2. promote client’s self. Surgical clients are at increased risk if alterations in nutrition and circulation are present. 2005 by Mosby. encourage early ambulation 87. promotes normal venous return and circulatory blood flow 98. Cause: Intractable pain may be related to the wound or dressing. All of the other clients are predisposed to an imbalance either to existing loses. the client is at increased risk for a wound infection because of bacterial contamination from the large intestine. Skin breakdown results from shearing during positioning on the OR table and improper pulling of the client up in bed. Increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment 95. provide meals when client is rested and free from pain 92. maintain a gradual progression in dietary intake (clear liquids.

the nurse determines that she is unable to read the font on the newspaper but that she can read the headlines with her glasses. and whom to call for questions. 2005 by Mosby. She does not recall receiving information about what to expect postoperatively. indicating that she needs further teaching and practice on IS use. “I had surgery over 20 years ago. I remember having more pain than I expected. when unmet. On admission to the hospital. Education has a beneficial effect in reducing postoperative anxiety. When the nurse asked Mrs. .g. The nurse explores with Mrs. Campana what she has been told regarding her surgery to which she responds that her surgeon explained the procedure with a drawing of the bowel and the location of the part to be removed. Campana’s demonstration of postoperative exercises. Reassure client that adequate pain management will be available. Campana has had previous surgery.. During your initial discussion with Mrs. Inc. Mrs. Campana what she has been told regarding preoperative preparation and what to expect postoperatively to which she states that she received information from the surgeon’s office about medicines to take the morning of surgery. Campana about previous surgeries and her experience with them. smells) needs to be structured. Campana and her Mosby items and derived items © 2009. IV. Psychological preparation for surgery reduces anxiety. She states that the booklet and audiotape were both helpful and that she has a good understanding of the typical postoperative course. nasogastric tube. She correctly demonstrates leg exercises and TC & DB but is having difficulty with IS use. The nurse understands that preadmission education often results in less teaching time and better performance of exercises on admission. you assess that she is alert and oriented. Preoperative teaching included providing Mrs. Teaching about sensory aspects (what the client sees. Campana and her daughter if they have any remaining fears or concerns. feels. as demonstration is an effective method to reinforce instruction. The nurse will make a follow-up call to client and her daughter encouraging them to ask questions and voice concerns and will document the education provided. Campana to describe typical monitoring and care activities following surgery and documented evaluation of her understanding. incisional pain. The nurse will have Mrs. Mrs. An instruction booklet designed for the visually impaired was also provided. Campana’s family/support system for preoperative and postoperative and determines that her daughter will be coming in town the day of surgery and will stay with her for two weeks after the surgery. You are the nurse in the ASC assigned to prepare Mrs. she replied.” The nurse asks Mrs.. Campana is able to verbalize typical monitoring and care following surgery. Campana for surgery. Campana with an audiotape program that explains preoperative and postoperative routines. wound care). Campana and her daughter the performance of postoperative exercises and how to get out of bed with assistance. and I was in the hospital for 10 days. Both Mrs. Campana or daughter have regarding surgery because unrealistic expectations.Study Guide Answer Key 175 99. Campana states that she has severely reduced visual acuity but is able to hear your questions clearly. Campana’s ability to read typical font type. an affiliate of Elsevier Inc. contribute to client’s anxiety. Campana. She lives alone and has a daughter who lives out of town. Upon assessment of Mrs. Campana is an 80-year-old client scheduled to be admitted in 5 days for elective bowel resection. The nurse has the opportunity to correct any unrealistic expectations Mrs. the nurse demonstrates to Mrs. Mrs. Mrs. The nurse assesses Mrs. The nurse asked Mrs. her diet before surgery and when to stop eating. The nurse also explains sensations to expect postoperatively (e. The nurse asks Mrs. The nurse observed Mrs. Campana demonstrate postoperative exercises before surgery to assess learning and provide an opportunity to reinforce instruction.

. Mosby items and derived items © 2009.Study Guide Answer Key 176 daughter deny any fears or concerns at the present time. Inc. an affiliate of Elsevier Inc. the informational and psychological needs of Mrs. Campana and her daughter have been met. 2005 by Mosby..

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