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.

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

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

an affiliate of Elsevier Inc. status) b. 6 structure (geographical boundaries. economic population (age and sex distribution. Because nurses provide direct care services where clients live and work. the coordinating of activities of multiple providers and payers in different settings throughout a client’s continuum of care 25. 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. Inc. ethnic and religious groups) c..Study Guide Answer Key 20. housing. education level. 2005 by Mosby. emergency services. observe the community’s design. growth trends. 3. 3. volunteer programs. 3. health teaching. may be involved in case finding. a. 23. and locations where the residents meet Mosby items and derived items © 2009. social (education and communication systems. government. welfare system) 22. it is important to focus on the individual and family and respect and incorporate the values of the community. 24. 4. location of services. . and tracking incident rates 21.

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

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

. The organization evaluates and analyzes current performance to use results to develop focused improvement actions. 28. 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. obtain information from populations regarding the frequency. 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. it involves finding out how well a program. procedure. goal is to understand the phenomena 19. design the study protocol c. steps of planning occur in an orderly fashion c. 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. with a focus on what people experience in regard to daily practices or experiences and how they interpret those experiences c. recruit subjects. 3. the conditions are tightly controlled to eliminate bias and to ensure that findings can be generalizable to similar subjects 20. distribution. 2005 by Mosby. empirical data is gathered e. a. and generalizable to subjects 18. 27. obtain necessary approvals. practice. 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. involves inductive reasoning to develop generalizations or theories from specific observations or interviews 23. or policy is working 22. 29. Inc. is a systematic step-by-step process that ensures that the findings from a study are valid. involves the description and interpretation of cultural behavior b. The summary details the results of the study and explains whether a hypothesis is supported. The results of other studies are not presented. . 4. 3. analyze the results of the study e. reliable. a. an affiliate of Elsevier Inc.Study Guide Answer Key 9 17. control external factors that may influence a relationship between the phenomena that are being studied d. identify the area of interest or clinical problem b. identify the problem area to be studied b. and interrelation of variables among the subjects 21. a. and implement the study d. formulate recommendations for future research 25.

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

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

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

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

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

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

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

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

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

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

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

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

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

Heteronomous morality: occurs between 4-7 years and is characterized by a belief that rules are unchangeable and that when a rule is broken. there is imminent justice b.. 17. an affiliate of Elsevier Inc. Briefly explain each. showing concern for others. and keeping mutual relationships) Stage 4: Society-maintaining orientation (expand their focus from a relationship with others to societal concerns) 19. 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. 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. Inc. Explain the two stages of Piaget’s moral development theroy a. Level I: Preconventional level: The person reflects on moral reasoning based on personal gain. . 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.Study Guide Answer Key 23 16. Autonomous morality: child understands that people make rules and that they can be changed Kohlberg identified six stages of moral development under three levels. 2005 by Mosby.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Determination of death requires irreversible cessation of circulatory and respiratory functions or that there is irreversible cessation of all functions of the entire brain. 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. needs to make the gift in writing with his or her signature. 10. when less restrictive interventions are not successful c. 9. It also is the most extensive law on how employers must treat health care workers and clients infected with HIV. only to ensure the physical safety of the resident or other residents b. 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. 5. 3. the hospital is not to discharge or transfer the client until the condition stabilizes. 11. an appropriate medical screening occurs within the hospital’s capacity. including the right to refuse treatment and formulate advance directives 13. an affiliate of Elsevier Inc. and offers legal immunity for nurses who help at the scene of an accident 20. including the brain stem. 2. An individual over the age of 18 has the right to make an organ donation. 8. 1. It also establishes the basis for privacy and confidentiality. 16. law that encourages health care professionals to assist in emergencies. Inc. written documents that direct treatment in accordance with a client’s wishes in the event of a terminal illness or condition 14. 7. . 4. provides rights to clients (protects individuals from losing their health insurance when changing jobs by providing portability) and protects employees. limits liability.. that when a client comes to the ER/hospital. 19. If an emergency exists. regulating health care and health care financing. a. 2005 by Mosby. and ensuring professional accountability for the care provided 21. Mosby items and derived items © 2009. only on the written order of a physician.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. which includes a specific episode with start and end times 18. 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. protection of the public’s health. 6. requires health care institutions to provide written information to clients concerning their rights under state law to make decisions. advocating for the rights of people. 17.

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

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

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

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

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

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

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

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

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

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

35.. 4. and acceptance of change in appearance or function 31. Refer to Figure 27. 2. 32. 29. statements of self-acceptance. proper nutrition. Attitudes toward body image can occur as a result of situational events such as the loss of or change in a body part. Will be able to voice the recognition that losing her job is not reflective of her worth as a person. involves attitudes related to the body. nonverbal behaviors indicating positive self-concept. The client will discuss a minimum of 3 areas of her life where she is functioning well. 2005 by Mosby. an affiliate of Elsevier Inc. regular exercise within client’s capabilities. Inc. stress-reducing practices 30. or function. . Will attend a support group for out-of-work professionals. Certain behaviors become common depending on whether they are approved and reinforced. including physical appearance.Study Guide Answer Key 57 28. 3. Adolescence is a particularly critical time when many variables affect self-concept and self-esteem. Mosby items and derived items © 2009. adequate sleep and rest. which is affected by cognitive and physical development as well as cultural and societal attitudes 33. 4.5 in the text. 34. structure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

as mixtures within large volumes of IV fluids b. recommended site for hepatitis B and rabies injections 99. injected into the dermis where medication is absorbed slowly 101. deep site away from nerves and blood vessels. 3. definition of pharmacokinetics 111. older children. child’s dose = surface of child/1. small (50-150 ml) containers that attach below the primary infusion bag 108. easily accessible but muscle not well developed. injection of a bolus or small volume of medication c. allows for administration of medications that are stable for a limited time in solution c. Mosby items and derived items © 2009. immunizations for children. and toddlers (immunizations) 97. cost-saving. convenience. definition of onset 113. not used in infants or children. a. 1. piggyback infusion 102. 2.7 m 2 x normal adult dose 115. a bolus may cause direct irritation to the lining of blood vessels 104. increased mobility. 2. safety. a. an affiliate of Elsevier Inc. 1. and comfort for the client 110. minimizes local skin irritation by sealing the medication in muscle tissue 100. 2005 by Mosby. use small amounts. potential for injury to radial and ulnar nerves. battery-operated and allows medications to be given in very small amounts of fluid (5-60 ml) 109. most dangerous method because there is not time to correct errors b. take insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn from the long-acting insulin first. 1. easily identified landmarks. preferred site for medications 98. 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. Inc. small (25-100 ml) IV bag connected to a short tubing line to the lower Y port of a primary infusion 107.or short-acting insulin with intermediate or long-acting insulin. lacks major nerves and blood vessels. a. less chance of contamination. it reduces risk for rapid-infusion by IV push b. if mixing rapid. absorption refers to the passage of medication molecules into the blood from the site of administration 112. it allows for control of IV fluid intake 105.Study Guide Answer Key 85 96. skin testing. . is an oral route 114. frequently used in infants. constant therapeutic blood levels 103.. a. rapid absorption. fast-acting medications must be delivered quickly b. a.

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

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

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

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

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

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

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

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

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

Place disoriented clients in room near nurses’ station. f. positioning for adequate ventilation and drainage or oral secretions. h. and place within easy reach. an affiliate of Elsevier Inc. 37. bathrooms. 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. or absorbed by the body 42. Remove clutter from bedside tables. reduce the risk of injury to others by the client 39. Show the client how to use the call light at the bedside and in bathroom. Explain seizure precautions to take: are nursing interventions to protect clients from traumatic injury. c. prevent the confused or combative client from removing life support equipment d. d.. b. Explain why an ambularm is used: a device that signals when the leg is in a dependent position 40. Place bedside tables and over-bed tables close to client. Place side rails in the up position. and secure safety straps around the client on a stretcher. 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. prevent interruption of therapy c. mechanical. Maintain close supervision of confused clients. A poison is: is any substance that impairs health or destroys life when ingested. List eight measures to prevent falls in the health care setting a. and providing privacy and support following the event Mosby items and derived items © 2009. . hallways. Lock beds and wheelchairs when transferring a client from a bed to a wheelchair or back to bed.Study Guide Answer Key 95 Acute Care 36. reduce the risk of client injury from falls b. 2005 by Mosby. and grooming areas. A physical restraint is: is a human. inhaled. Inc. e. g. Use of restraints must meet the following objectives a. Leave one side rail up and one down on the side where the oriented and ambulatory client gets out of bed.

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

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

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

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

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

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

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

e 14. g 7. Regular rhythm. a. i 16. a 8.12 seconds) 12. c 23. impulse travel time through the AV node (. g 15. a. chronic diseases (chronic hypoxemia) 25. conduction thru both atria 10. d 19. myocardial hypoxia. j 17. impaired valvular function. an affiliate of Elsevier Inc. rate less than 60 c. . trauma. muscular disease. 2005 by Mosby. rate greater than 100 b. time needed for ventricular depolarization and repolarization (0. alterations that affect the oxygen-carrying capacity (anemia) c.Study Guide Answer Key Chapter 40: Oxygenation 103 1. hypovolemia (shock and severe dehydration) e.12-0. pregnancy (inspiratory capacity declines) b.012 -. b 6. hypoventilation. a. e 3. hypoxia) b. h 4.20 seconds) 11. incisions) e. and peripheral tissue hypoxia Respiratory disorders (hyperventilation. obesity (reduced lung volumes) c. CNS (reduced inspiratory lung volumes) g. increased metabolic rate (pregnancy. trauma (flail chest. c 2. drug overdoses) d. h 18. neuromuscular diseases (decrease the ability to expand and contract the chest wall) f.06 – 0. decreased inspired oxygen concentration (high altitudes. Electrical impulse in the atria is chaotic and originates from multiple sites Mosby items and derived items © 2009. the impulse traveled through the ventricles (0. infection) 24.. f 20. fever.42 seconds) 13. Inc. f 5. a 22. musculoskeletal abnormalities (structural configurations. Regular rhythm. b 21. d 9. cardiac disorders: disturbances in conduction. cardiomyopathic conditions. CNS) d.

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

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

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

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

Edwards’ statement indicates that he has a cough.. 1. and his vital signs are 100. CPT includes postural drainage. All other answers are related to the subjective sensation of dyspnea. Gases move into and out of the lungs through pressure changes (intrapleural and atmospheric). His SpO2 ranges from 78-84%. 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. physical assessment data 86. Edwards effective cough techniques to clear secretions. . percussion. 88. Edwards’ skin and mucus membranes are dry. Interventions based upon the data would include increasing fluids to 1000 mL in 24 hours to liquefy secretions. does not exercise. he has abnormal breath sounds in the lower lobes and has a productive cough of thick and discolored yellow-to-yellow green sputum. Mosby items and derived items © 2009. The heart must work to overcome this resistance to fully eject blood from the left ventricle. Mr. is fatigued. VS d. evaluation of ABGs b. Initiate chest physiotherapy (CPT) if there is evidence of infiltrates on chest X-ray. These are the 3 steps in the process of oxygenation. and continues to smoke ½ pack of cigarettes a day. 91. 3. 2.Study Guide Answer Key 108 84. ECG e. PFTs c. 90. improves efficiency of breathing by decreasing air trapping and reducing the work of breathing 85. 89. 130/90. Mr. a. and teach Mr. Inc. an affiliate of Elsevier Inc. Edwards deepbreathe and cough every 2 hours 4 to 5 times. 2. 87. 2005 by Mosby. have Mr. 1. 26 SpO2 87%. and vibration. 88.4.

fluid output 19. negatively charged electrolytes (chloride. kidneys. at risk are clients who are unable to perceive or respond to the thirst mechanism 22. the difference between 2 concentrations 16. and proteins 6. hormonal controls c. is the fluid outside the cell (interstitial. a solution of lower osmotic pressure (moves fluids into the cells. is continuous and occurs through the skin and lungs. glucose. lungs. occurs through excess perspiration and can be perceived by the client 27. causing them to shrink) 13. causing them to enlarge) 14. and transcellular fluid) 2. are electrolytes. moving from an area of higher pressure to one of lower pressure 17. or both. a. 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. Inc. excess fluid is lost 21. which reflects the amount of a substance in the form of molecules. represents the number of grams of the specific electrolyte dissolved in a liter of plasma 5. comprises all fluid within the cells of the body (42% of body weight) b. relocates blood flow to kidneys and stimulates the release of aldosterone (when the sodium is low) c. the osmotic pressure of a solution 10. potassium. and Acid-Base Balance 109 1. a. not perceived by the person b. 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. ADH – is stored in the pituitary gland and is released in response to changes in the blood osmolarity 23. carbon dioxide. oxygen. 2005 by Mosby. skin. and calcium) 3. and sulfate) 4. an affiliate of Elsevier Inc. intravascular. another term that describes the concentration of solution 11. a solution of higher osmotic pressure (pulls fluid from cells. 8. is the process by which water and diffusible substances move together across a membrane. requires metabolic activity and expenditure of energy to move substances across the cell membrane 18. Mosby items and derived items © 2009. fluid intake b. massive selective vasoconstriction of blood vessels. plays a critical role in the balance of fluid and electrolytes and the maintenance of vascular tone 25. is the drawing power of water and depends on the number of molecules in solution 9. continually monitor the serum osmotic pressure 20. bicarbonate. . positively charged electrolytes (sodium. in response to fluid pressure. Electrolyte. 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. The concentration of a solution is measured. ions. causes vasoconstriction b. gastrointestinal tract 26. adrenal cortex releases in response to increased plasma potassium levels 24..Study Guide Answer Key Chapter 41: Fluid. a. a.

biological c. chemical b. intestinal absorption. Regulatory Mechanism Dietary intake and aldosterone secretion Dietary intake and renal excretion regulate potassium. neurochemical activities. Serum magnesium is regulated by dietary intake.. Inc. Phosphate is normally absorbed through the GI tract.8-4.5-2. vitamin D & calcitonin. transmission and conduction of nerve impulses.0 mEq/L Calcium 4. blood clotting.5 mg/dl Function Major contributor to maintaining water balance Is necessary for glycogen deposits in the liver and skeletal muscle. and cardiac and skeletal muscle excitability Chloride is the major anion in ECF. The bicarbonate ion is an essential component of the carbonic acid-bicarbonate buffering system essential to acid-base balance.5 mEq/L Chloride 95-105 mEq/L Bicarbonate 22-26 (arterial) mEq/L 24-30 (venous) mEq/L Phosphate 2. It assists in acid-base regulation. Regulated by parathyroid hormone. and PTH. Phosphate and calcium help to develop and maintain bones and teeth. Phosphate also promotes normal neuromuscular action and participates in carbohydrate metabolism. hormone secretion. and muscle contraction Essential for enzyme activities.5-5. transmission of nerve impulses.5 mg/dl Absorbed from intestine. physiological buffering Mosby items and derived items © 2009. Magnesium 1. renal excretion.5-5. renal mechanisms. normal cardiac conduction. cardiac conduction. an affiliate of Elsevier Inc. 28. The kidneys regulate bicarbonate. Serum chloride is regulated by dietary intake and the kidneys. cell membrane integrity. The transport of chloride follows sodium. It is regulated by dietary intake. a. excreted by the kidneys and resorption or deposition in bone. and skeletal and smooth muscle contraction Bone and teeth formation.Study Guide Answer Key 110 Electrolyte Values Sodium 135-145 mEq/L Potassium 3. . 2005 by Mosby. and actions of the parathyroid hormone (PTH).

. paresthesias.. decreased bowel wave. convulsions. and urine tongue and mucous specific gravity 1. and wave and widened QRS diarrhea complex (bradycardia. mg/dl and ECG hyperactive reflexes. an affiliate of Elsevier Inc. diarrhea. intestinal abnormalities: flattened T distention. dry and 145 mEq/L. 2005 by Mosby. 5. nausea electrocardiogram (ECG) and vomiting. serum osmolality 280 mOsm/kg. ST segment sounds. convulsions. dysrhythmias.0 mEq/L and ECG paresthesia. weakness.g.Study Guide Answer Key 111 29.030 (if not membranes. irregular pulse dysrhythmias) serum potassium level above anxiety. heart block. postural caused by diabetes insipidus) hypotension. abnormalities: ventricular positive Trousseau’s sign tachycardia (carpopedal spasm with hypoxia). . restlessness. tachycardia. postural dizziness.010 (if not caused by SIADH) Signs and Symptoms apprehension. fever. tendon reflexes. nausea and vomiting. abdominal cramping. and irritability serum potassium level below weakness and fatigue. and urine specific gravity below 1. abnormalities: peaked T abdominal cramps.5 mEq/L or total fingers and circumoral serum calcium below 8. postural hypotension. ventricular potentiated digoxin effects dysrhythmias. 3. eventually QRS pattern widens.5 mEq/L and muscle weakness.5 (around mouth) region. decreased deep depression. positive Chvostek’s sign (contraction of facial muscles when facial Hypernatremia Hypokalemia Hyperkalemia Hypocalcemia Mosby items and derived items © 2009. agitation. (e. and coma serum sodium levels above extreme thirst. Imbalance Hyponatremia Lab Finding serum sodium level below 135 mEq/L. serum osmolality flushed skin. personality change. dysrhythmias). ventricular and weak. dry and sticky 300 mOsm/kg. u wave. Inc. dry mucous membranes. and cardiac arrest occurs serum ionized calcium level numbness and tingling of below 4.

decreased level of consciousness.35-7. measures the hydrogen ion concentration in the body fluids (7. is the point at which hemoglobin is saturated by oxygen (95-99% ) e. ECG abnormalities: heart block serum magnesium level below 1. tetany.5 mEq/L Hypermagnesemia serum magnesium level above 2. tachycardia. 2005 by Mosby. personality changes. dysrhythmias. hypotension. confusion and disorientation.5 mEq/L or total serum calcium level above 10. ECG abnormalities: prolonged QT interval. hypoactive reflexes. is the partial pressure of oxygen in the blood (80-100) d. flank pain (from kidney stones). is the major renal component of acid-base balance (22-26) Mosby items and derived items © 2009. and elevated blood urea nitrogen (BUN) level 25 mg/100 ml and elevated creatinine level 1. hypertension. decreased depth and rate of respirations.45) b. and positive Chvostek’s sign and Trousseau’s sign acute elevations in magnesium levels: hypoactive deep tendon reflexes. and pathological fractures (chronic hypocalcemia) anorexia.. lethargy. muscle cramps. radiopaque urinary stones. Inc. nausea and vomiting. hyperactive deep tendon reflexes.Study Guide Answer Key 112 nerve is tapped). x-ray examination showing generalized osteoporosis. and cardiac arrest Hypercalcemia Hypomagnesemia serum ionized calcium level above 5.2) f. is the partial pressure carbon dioxide in arterial blood (35-45) c. AV block muscular tremors.5 mEq/L. a. . an affiliate of Elsevier Inc. weakness. widespread bone cavitation. is the amount of blood buffer (hemoglobin and bicarbonate) that exists (+/. and flushing 30.5 mg/dl.5 mg/100 ml caused by fluid volume deficit (FVD) or renal damage caused by urolithiasis.

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

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

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

33% sodium chloride (one-third normal saline) c.45% NaCl sodium chloride. 116 Hypotonic: 0. Hypertonic: Dextrose 10% in water.45% sodium chloride (half normal saline). 0.. Inc. . dextrose 5% in lactated Ringer’s Mosby items and derived items © 2009. dextrose 5% in 0. 3%-5% sodium chloride. dextrose 5% in 0.9% sodium chloride. 2005 by Mosby.Study Guide Answer Key b. an affiliate of Elsevier Inc.

translucent Gross edema >6 inches in any direction Cool to touch Mild to moderate pain Possible numbness 4 Skin blanched.. < 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. Inc. 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. Infiltration Scale Grade Clinical Criteria 0 1 No symptoms Skin blanched Edema.Study Guide Answer Key 117 67. translucent Skin tight. 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. . 2005 by Mosby. bruised. an affiliate of Elsevier Inc. irritant. leaking Skin discolored.

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

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. a. excess carbonic acid. and turn on NS that is connected to the Y-tubing infusion set. . and marked hypotension and shock 119 Circulatory overload Sepsis 79. d. Remain with client. and an increased hydrogen ion concentration 90. attached labels. anxiety with hyperventilation is a cause 92.9% NS. headache. Fad dieting – metabolic acidosis c. sudden chills and fever. 87. 83. Inc. shock. Prepare to perform cardiopulmonary resuscitation. 82. is marked by a decreased PaCO2 and an increased pH. Any condition that results in the loss of GI fluids predisposes the client to the development of dehydration and a variety of electrolyte disturbances.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. dyspnea. possible cardiac arrest Cough. 89. hypertension. Keep the IV line open with 0. headache. tachycardia. 81. Extracellular fluid is all the fluid outside of the cell and has 3 compartments. and transfusion record are saved and returned to the lab. The blood container. Do not turn off the blood. 3. Steroid use – metabolic alkalosis b. muscle pain 80. vomiting. an affiliate of Elsevier Inc. 2005 by Mosby. anxiety. tubing. 91. distended neck veins Rapid onset of chills. 3. observing signs and symptoms. 85. monitor VS every 5 minutes. 88. 84.. 1. 86. 4. pulmonary congestion (rales). diarrhea. Notify health care provider. flushing. urticaria. wheezing progressing to cyanosis. high fever. Chronic alcoholism – respiratory acidosis Mosby items and derived items © 2009. Obtain a urine specimen and send to lab (RBC hemolysis). a combination of increased PaCo2. Prepare to administer emergency drugs per protocol.

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

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

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

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

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

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

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

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

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

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

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

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

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

diarrhea. botulism: Improperly home-canned foods. lunch meats). sandwich fillings. salad dressings. feeding self-care deficit 65. pate. minimizes the hypermetabolic response to trauma c. staphylococcus: Severe abdominal cramps. Inc. seafood d. appropriate assessment of nutrition needs Mosby items and derived items © 2009. imbalanced nutrition: more than body requirements 62.0-2. loses at least ½ to 1 pound per week 66.8 – 4. pain. ham. refrains from eating unhealthy foods between meals and after dinner e. . dysphagia puree b. egg dishes. shigellosis: Milk.Study Guide Answer Key 136 61. not nutritionally complete c. regular 69. perfringens enteritis: Cooked meats. nectar-like liquids (medium viscosity) c. sausage.0 kcal/mL) predigested nutrients that are easier for a partially dysfunctional GI tract to absorb d. meat dishes held at room or warm temperature e. (1. custards. Appears 1-6 hours after ingestion and lasts 1-2 days 67. thin liquids (low viscosity) b. decreased level of alertness. seafood. poultry. 2005 by Mosby. milk products.0 kcal/mL) single macronutrient preparations.0-3. and clients who have difficulty managing saliva 68. spoon-thick liquids (pudding) 70.. a. a. (1. a. reduces sepsis b. headache. dysphagia advanced d. an affiliate of Elsevier Inc. listeriosis: Soft cheese. fever. a. shellfish b. nutritional intake meets the minimal DRIs b. dysphagia mechanically altered c.0 kcal/mL) designed to meet specific nutritional needs in certain illnesses 71. readiness for enhanced nutrition 64. risk for imbalanced nutrition: more than body requirements 63. salads g. fat nutritional intake is less than 30% c.0 kcal/mL) milk-based blenderized foods b. prostration. salmonellosis: Milk. a. honey-like liquids d. removes sugared beverages from the diet d. polluted shellfish f. maintains intestinal structure and function 72. meat (hot dogs. (1. smoked and salted fish. vomiting. a. decreased gag and/or cough reflexes. unpasteurized milk. (3. perspiration. escherichia: Undercooked meat (ground beef) c. a.0-2.

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

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

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

and collect 30 to 60 ml. 38.0053-1. protein (none or up to 8 mg/100 ml). retract the foreskin before cleansing. specific gravity (1. The client voids into a clean receptacle. pale. After client has initiated urine stream. Sterile: If the client has an indwelling catheter. b. Using sterile aseptic technique. moving from front (above urethral orifice) to back (toward anus). straw-colored to amber-colored depending on its concentration 35. . will analyze values of pH (4. insert a sterile syringe hub and withdraw at least 3 to 5 ml of urine (check agency policy).0).6-8. and using circular motion and antiseptic swab. rinse area with sterile water. have client initiate stream. hold penis with one hand. the stronger the odor 37. bladder. After the nurse wipes the port with an antimicrobial swab.While continuing to hold labia apart. If agency policy indicates. Male – After donning sterile gloves.Study Guide Answer Key 140 32. Missed specimens make the whole collection inaccurate. ketones (none). and dry with dry cotton ball or gauze. Client finishes voiding in bedpan or toilet. repeat front-to-back motion three times (begin with center. Using a fresh swab each time. and crystals (none). a. has a characteristic odor. transfer the urine to a sterile container. WBCs (0-4 per low-power field). 12-. Check with agency policy and the laboratory for specific instructions. Client finishes voiding in bedpan or toilet. After client achieves a stream. pass specimen collection container into stream. sterile or clean voided sample of urine and can report bacterial growth in 24-48 hours 41. glucose (none). rinse area with sterile water. is the weight or degree of concentration of a substance compared with an equal volume of water 40. Clamp the tubing below the port. allowing fresh. then left side then right side). and the urine is transferred to the special collection container. casts (none). moving from center to outside (see illustration). Each specimen must be free of feces and toilet tissue. or 24-hour collections. Inc. collect a sterile specimen by using aseptic technique through the special sampling port (Figure 45-7) found on the side of the catheter. If agency procedure indicates. becomes more cloudy on standing in a container 36. Female – After donning sterile gloves. the more concentrated the urine. cleanse end of penis. 39. d. uncontaminated urine to collect in the tube. spread labia with thumb and forefinger of nondominant hand.. Cleanse area with cotton ball or gauze. skin and mucosal membranes. In uncircumcised men. Timed urine: Time required may be 2-. Clean-voided or midstream: Use a sterile specimen cup. bacteria (none). 2005 by Mosby. appears transparent at voiding. Remove specimen container before flow of urine stops and before releasing labia or penis. pass container into stream and collect 30 to 60 ml.030) and microscopic values for RBCs (up to 2). blood. 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. Mosby items and derived items © 2009. c. which often contains special preservatives. urethral meatus 34. Use a clean specimen cup. Remove specimen container before flow of urine stops and before releasing labia or penis. c 33. and dry with cotton or gauze. kidneys. Random: Collect during normal voiding from an indwelling catheter or urinary diversion collection bag.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

.g. • Change in total amounts of body potassium and water volume: Greater risk for fluid or electrolyte imbalance occurs. alter normal clotting factors and thus increase risk of hemorrhaging. a difficulty resuming activity after surgery b. Mosby items and derived items © 2009. Anticonvulsants: Long-term use of certain anticonvulsants (e. aminoglycosides (gentamycin. Inc. 2005 by Mosby. neomycin) may cause mild respiratory depression from depressed neuromuscular transmission. IV fluids. reducing amount of new air brought into lungs with each inspiration • Stiffened lung tissue and enlarged air spaces: Alteration reduces blood oxygenation. 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. medications 19. Antibiotics: Antibiotics potentiate (enhance action) of anesthetic agents. Discontinued at least 48 hours before surgery. Anticoagulants: Anticoagulants.Study Guide Answer Key 168 17. reduced ventilatory and cardiac function c. neurological system: • Sensory losses. can reduce cardiac contractility and impair cardiac conduction during anesthesia. high risk of dehiscence and evisceration 18. beta blockers such as metoprolol [Lopressor®]).. . 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.. poor wound healing and wound infection d. 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. such as warfarin (Coumadin®). tobramycin. • Increase in calcium and cholesterol deposits within small arteries. If taken within 2 weeks before surgery. exposure of body parts during procedure. Antidysrhythmias: Antidysrhythmics (for example. phenytoin [Dilantin®] and phenobarbital) alters metabolism of anesthetic agents. an affiliate of Elsevier Inc. • Impaired thermoregulatory mechanisms: Cold operating rooms. Aspirin is a commonly used medication that alters clotting mechanisms.

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

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

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

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

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

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

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

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

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