Nursing Final Exam Questions with Answers with Latest Updates 2023/2024 100% Verified, Exa, Exams of Nursing

Download Nursing Final Exam Questions with Answers with Latest Updates 2023/2024 100% Verified, Exa and more Exams Nursing in PDF only on Docsity!

Nursing Final Exam Questions with Answers

with Latest Updates 2023/2024 100% Verified,

Exams of Nursing

1. How can you estimate a client's tidal volume? - Answer : :Tidal volume can be estimated by observing the depth of the client's respirations.
2. What is the range of normal for an adult's respiratory rate? - Answer : :A rate of 12 to 20 breaths per minute is normal for adults
3. Besides the rate, what other characteristics of a client's respirations should you observe? - Answer : :Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to rate.
4. What are some common clinical signs associated with poor oxygenation? - Answer : :Pallor or cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation.
5. Which of the Korotkoff sounds would you record as the systolic pressure? - Answer : :First
6. Which of the Korotkoff sounds would you record as the diastolic pressure? - Answer : :Fifth
7. A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately. At 150 mm Hg, the sound appears again and continues until there is silence at 80 mm Hg. The pressures were taken in the client's right arm while the client was lying down.
8. How should the nurse record these pressures? - Answer : :BP RA, supine, 170/80 with an auscultatory gap from 170 to 150

9. How do you explain what happened? - Answer : :An auscultatory gap occurred. A gap is most commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal limit of 140 mm Hg.
10. Which of the following patients has hypertension? One with a BP of:
11. 150/80 on two separate occasions
12. 180/100 on one occasion
13. 138/88 on two occasions - Answer : :150/80 on two separate occasions
14. Which of the following client(s) has/have primary hypertension?
15. Client A, who is obese and has a high sodium intake
16. Client B, who is in renal failure
17. Client C, who has hypertension induced by pregnancy
18. Client D, who has a family history of hypertension - Answer : :Client D, who has a family history of hypertension
19. What are five functions of the skin? - Answer : :The skin serves five functions: protection, sensation, temperature regulation, secretion/excretion, and formation of vitamin D.
20. How does the skin help regulate body temperature? - Answer : :The skin contains sensory organs or receptors for heat and cold. The skin regulates temperature through the process of dilating and constricting blood vessels and activating or inactivating sweat glands. The sweat glands found in the axillae and external genitalia secrete fatty acids and proteins and excrete perspiration, which produces a cooling effect as the moisture evaporates from the skin.
21. What changes take place in the skin as a person ages - Answer : :With age, both layers of the skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly, and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity of hair follicles and pigment cells

(melanocytes) diminishes, hair becomes thin, turns gray or white, and grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin problems.

22. True or false: The professional nurse is responsible for making assessments. - Answer : :True
23. True or false: Assisting with the bath is an excellent time to assess the patient. - Answer : :True
24. To inspect for pallor in a dark-skinned person, which areas would you assess for an ashen gray or yellow color? - Answer : :For dark-skinned persons, the conjunctivae, buccal mucosa, tongue, lips, nail beds, palms, and soles should be assessed for pallor.
25. What is the term that means "a bluish color of the skin"? - Answer : :Cyanosis means a bluish discoloration of the skin.
26. Name two causes of erythema. - Answer : :Vasodilation and inflammation are causes of erythema.
27. Where can you best see jaundice? - Answer : :The sclera of the eyes is the best place to see jaundice
28. True or false: Healthy nails are usually clean, smooth, and convexly curved - Answer : :True
29. List at least three nail changes that occur with aging. - Answer : :As a person ages, the nails thicken, become ridged, and may yellow or become concave in shape.
30. List at least four things you should teach clients about self-care of their nails. - Answer : : Answer ::
31. Clients should be taught the following self-care of their nails:
32. ● Inspect the nails daily.
33. ● Trim nails with a nail clipper (people with diabetes or circulatory problems should file only, as cutting poses a risk for injury to the tissues).
34. ● File the nails straight across, rounding the corners slightly to prevent scratching; do not cut deeply into the lateral corners, as this may cause ingrown nails.

35. ● Remove hangnails by carefully cutting them off.
36. ● Clean under the nails with an orangewood stick or other blunt instrument.
37. ● Push back the cuticles gently.
38. ● Use a moisturizing lotion to soften cuticles.
39. ● Avoid biting nails.
40. ● Consult a podiatrist for any ingrown toenails or other nail problems.
41. ● Recommend to patients with diabetes, circulatory insufficiency, or nail problems that they seek nail care from a podiatrist.
42. List at least four assessments you should make of a patient's hair. - Answer : :The following assessments should be made on a patient's hair:
43. ● Use of special products or medicated shampoos
44. ● History of hair problems or current conditions necessitating treatment (e.g., pediculosis [head lice])
45. ● History or presence of disease or therapy that affect the hair (e.g., chemotherapy)
46. ● Factors influencing the patient's ability to manage hair and scalp care (e.g., Impaired Mobility)
47. ● Personal or cultural preferences for styling of the hair
48. ● Condition, cleanliness, texture, and oiliness of the hair
49. ● Inspection of the scalp for dandruff, pediculosis, alopecia (hair loss), secretions or lesions
50. What is pediculosis? - Answer : :Pediculosis is an infestation of head lice
51. What is alopecia? - Answer : :Alopecia is hair loss.
52. Identify the components of verbal and nonverbal communication. - Answer : :Verbal communication. Vocabulary, denotative and connotative meaning, pacing, intonation, clarity and brevity, timing and relevance, credibility, and humor are the components of verbal communication.

53. ● Nonverbal communication. Facial expression, posture and gait, personal appearance, distance, gestures, and touch are the components of nonverbal communication.
54. What action should you take when there is a discrepancy between the client's spoken word and nonverbal body language? - Answer : :You must discuss the communication discrepancy with the patient.
55. Identify and describe the phases of the therapeutic relationship. - Answer : :The therapeutic relationship has four phases: pre-interaction, orientation, working, and termination.
56. ● The pre-interaction phase occurs before you meet the client. In this phase you gather information about the client.
57. ● The orientation phase begins when you meet the client. The goal of this phase is to establish rapport, trust, and a timeline.
58. ● The working phase is the active part of the relationship. During this phase, caring is communicated, thoughts and feelings are expressed, mutual respect is maintained, and honest verbal and nonverbal expression occurs.
59. ● The termination phase is the conclusion of the relationship.
60. What are the five characteristics of therapeutic communication? - Answer : :The five characteristics of therapeutic communication are empathy, respect, genuineness, concreteness, and confrontation.
61. Describe the difference between a task group and a self-help group. - Answer : :A task group is developed to address a task or need. Members are chosen based on ability to complete the task.
62. ● A self-help group is a voluntary organization composed of individuals with a common need. The organization revolves around a belief that the experience of others who have resolved the need assists others with the need.

63. Compare and contrast the role of a therapy group with a work-related support group. - Answer : :● A therapy group helps members cope with issues, improve relationships, or address stress. It is a formal, organized group with a facilitator.
64. ● A work-related support group helps members of a profession cope with the stress associated with their work. It may be a formal or informal group.
65. Identify at least five barriers to communication. - Answer : :Any five of the following common barriers to communication would be an appropriate Answer ::
66. ● Asking too many questions
67. ● Asking why
68. ● Changing the subject inappropriately
69. ● Failing to listen
70. ● Failing to probe
71. ● Expressing approval or disapproval
72. ● Offering advice
73. ● Providing false reassurances
74. ● Stereotyping
75. ● Using patronizing language
76. What is a pathogen? - Answer : :Pathogens are bacteria, viruses, fungi, and other organisms that cause disease.
77. What is the role of normal flora? - Answer : :Normal flora are nonpathogenic microorganisms that help to control the growth of pathogenic microorganisms. Normal flora in the intestine also aid digestion and, when they die, release vitamins important to human health.
78. Identify at least five reservoirs of infection. - Answer : :Potential Answer :s include the following reservoirs of infection:
79. ● Human body

80. ● Animals
81. ● Insects
82. ● Food
83. ● Floors in healthcare facilities
84. ● Bathrooms
85. ● Raw sewage
86. ● Stagnant water
87. ● Garbage
88. ● Diapers
89. ● Used wound dressings
90. Identify the six links in the chain of infection. - Answer : :The following six links compose the chain of infection:
91. ● Infectious agent
92. ● Reservoir
93. ● Portal of exit
94. ● Mode of transmission
95. ● Portal of entry
96. ● Susceptible host
97. What kinds of microbes favor the human body as a reservoir of infection? - Answer : :The human body provides a warm, moist environment. The microbes that are pathogenic to humans are so because they thrive at about the same temperature as the human body. To thrive in the human body, microbes also must be able to use the body's precise balance of moisture, nutrients, electrolytes, and pH to support their own reproduction.
98. Identify and describe the purpose of the body's three major lines of defense against infection. - Answer : :● The primary defense mechanisms prevent entry of pathogens into the body. Primary defense mechanisms include intact skin, mucous membranes at body

openings, normal flora, and a rich vascular supply at potential sites of entry for infection, including the mouth and vagina. They also include processes such as crying, salivating, vomiting, peristalsis, and diarrhea.

99. ● The secondary defense mechanisms are activated if a pathogen gains entry into the body. Secondary defense mechanisms include phagocytosis, the complement cascade, inflammation, and fever.
100. ● Specific immunity, a third line of defense, protects against specific pathogens and builds immune "memory" in the process. The humoral response produces antibodies that inactivate invading antigens. The cell-mediated response results in the production of T cells that destroy body cells infected with invaders.
101. Mr. Jefferson has an acute infection. If lab work reveals that IgM, but not IgG, is present in his blood, what can you conclude about this infection? - Answer : :IgM is present the first time an individual is exposed to a particular pathogen. If IgG is not present, you can conclude that the exposure occurred less than 10 days ago.
102. What factors increase a client's risk for infection? - Answer : :The following factors increase a client's risk for infection:
103. ● Very young children and older adults are at increased risk for infection. Young children have limited exposure to pathogens and little active immunity. Older adults have declining function of the immune system and limited physiological reserve.
104. ● Any break in the skin also increases risk.
105. ● Illness and injury, especially chronic disease, limit an individual's ability to fight infection.
106. ● Smoking, substance abuse, and multiple sex partners increase the risk of infection.
107. ● Some medications inhibit the immune response of the body.
108. ● Environmental factors that increase exposure to pathogens increase risk for infection.

109. ● Finally, nursing and medical treatments often provide portals of entry and exit or bypass natural defense mechanisms.
110. Under what circumstances are standard precautions used? - Answer : :Standard precautions are used on all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions and secretions, mucous membranes, and any break in the skin.
111. When will you need to don sterile gloves using the closed method? - Answer : :When you are performing an activity that requires you to wear a sterile gown. The gloves must cover the gown cuffs.
112. True or false: Some procedures require both standard precautions and sterile technique - Answer : :Healthcare providers use sterile technique to perform a variety of procedures. Some of the procedures require full surgical attire; others do not. The following procedures, for example, use both sterile technique and principles of medical asepsis: administering an injection, starting an IV line, and performing a sterile dressing change. To clarify, when administering an injection, you prepare the patient, cleanse the injection site, and remove the needle cap using standard precautions. You do not don sterile gloves, but for the rest of the procedure you observe sterile technique by taking care not to touch or otherwise contaminate the exposed needle.
113. What part(s) of a sterile field are considered to be unsterile? - Answer : :A 1-inch margin around the edges of the field and any material that hangs over the horizontal plane are considered unsterile. You may also recall that a field is no longer sterile if it becomes wet, if you turn your back on it, or if someone not wearing sterile garb comes within 1 foot of the field.
114. State whether each of the following represents a nursing diagnosis, medical diagnosis, or collaborative problem.

1. All women after giving birth to a baby are at risk for developing postpartum hemorrhage
2. A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics.

115. 3)A client is at risk for constipation because he postpones defecation and also does not get enough dietary fiber and fluids. The problem can be prevented by patient teaching, which the nurse is licensed to do. - Answer : :1)Collaborative problem (potential complication of childbirth: postpartum hemorrhage)
116. Rationale:
117. This is a potential problem that the nurse can help to prevent (e.g., by fundal massage); but if fundal massage is not effective, the physician must prescribe medication to prevent hemorrhage. This is a potential physiological complication associated with a medical diagnosis (childbirth).
118. 2)Medical diagnosis: appendicitis (actual problem; nurse cannot treat independently; requires surgery and antibiotics)
119. 3)Nursing diagnosis
120. Rationale:
121. The problem can usually be prevented by independent nursing interventions. Medication is sometimes prescribed, but not usually.
122. What are the five types of nursing diagnoses that can be used? - Answer : :1. Actual nursing diagnosis
123. 2. Risk (potential) nursing diagnosis
124. 3. Possible nursing diagnosis
125. 4. Syndrome nursing diagnosis
126. 5. Wellness nursing diagnosis

127. "Collaborative problems" is incorrect. Collaborative problems are a type of problem, but not a type of nursing diagnosis.
128. What kind of nursing diagnosis is each of the following? - Answer : :a. Jane Thomas regularly engages in exercise but tells you she would like to increase her endurance.
129. Answer ::
130. Wellness diagnosis
131. b. Mrs. King has several of the signs and symptoms (defining characteristics) of the nursing diagnosis Ineffective Coping
132. Answer ::
133. Actual diagnosis
134. c. Alicia Hernandez seems anxious, but you are not sure. You would like to have more data in order to diagnose or rule out a diagnosis of Anxiety.
135. Answer ::
136. Possible diagnosis
137. d. Charles Oberfeldt has no symptoms of constipation, but he reports that he does not include many fiber-rich foods in his diet and drinks few liquids. In addition, he is now fairly inactive because of a back injury. These are all risk factors for a diagnosis of Constipation.
138. Answer ::Risk diagnosis
139. What is a cue? - Answer : :Significant data (also called cues) are data that influence your conclusions about the client's health status (or that influence your choice of nursing

diagnoses). A cue should alert you to look for other cues that might form a cluster (pattern) representing a nursing diagnosis.

140. What are five ways you can recognize a cue? - Answer : :A cue is recognized by the presence of data representing (1) a deviation from population norms, (2) a change in usual health patterns that is not explained by developmental or situational changes, (3) an indication of delayed growth and development, (4) a change in usual behaviors in roles or relationships, or (5) a nonproductive or dysfunctional behavior.
141. What are the possible conclusions you can draw about a client's health status (e.g., that no problem exists)? - Answer : :You might conclude that there is a patient strength, no problem, a wellness diagnosis, a possible problem, an actual nursing diagnosis, a risk (potential) nursing diagnosis s, a collaborative problem, or a medical diagnosis.
142. What is the difference between a cue and an inference? - Answer : :A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. You can observe a cue directly, but not an inference. You cannot directly check the accuracy of an inference.
143. How can you be satisfied that you have made a valid inference? - Answer : :The more data and theoretical knowledge you have to support an inference, the more sure you can be that it is valid/accurate.
144. List the steps in the diagnostic process. - Answer : :1. Analyzing and interpreting data (this includes identifying significant data, clustering cues, and identifying data gaps and inconsistencies)
145. 2. Drawing conclusions about health status (this includes making inferences and identifying problem etiologies)
146. 3. Verifying problems with the patient

147. 4. Prioritizing the problems
148. 5. Recording the diagnostic statements (it could be argued that this is not really a "part of" the diagnostic process)
149. What is a typical cause of fire in healthcare facilities - Answer : :Fire in healthcare facilities is typically related to anesthesia or electrical causes.
150. Which assessment tool would you use for a slightly confused home care client to assess her ability to safely live alone and perform activities of daily living? - Answer : :The Safety Assessment Scale (SAS) primarily evaluates whether the cognitively impaired person is capable of cooking, taking her own medicines, shopping, and performing other activities of daily living.
151. ● List the six risk factors that are assessed on the Morse Fall Scale. - Answer : :The following six risk factors are assessed on the Morse Fall Scale:
152. Whether the patient has a history of falling
153. Whether the person has more than one medical diagnosis
154. Whether the person uses ambulatory aids, such as crutches or a walker
155. Whether the person has an IV or a heparin lock
156. Whether the person's gait is normal, stooped, or otherwise impaired
157. The person's mental status
158. How should you screen older adults to see if they need a comprehensive falls evaluation? - Answer : :Use the Get Up and Go test, and possibly the Timed Up and Go test if indicated.
159. What does the nurse do in the planning phases of the nursing process? - Answer : :In the planning phases, the nurse chooses outcomes/goals based on assessments and nursing diagnoses, chooses nursing interventions, and writes the plan of care.

160. What is the purpose of initial planning? Ongoing planning? Discharge planning? - Answer : :● Initial planning is done for the purpose of identifying patient problems and creating the care plan.
161. ● Ongoing planning allows you to revise and individualize the patient's care plan as new data are obtained.
162. ● Discharge planning is done to evaluate the patient's health status on leaving the institution, to prepare the patient for self-care, to prepare family members for caregiving, and to coordinate services that will be needed after the patient leaves the hospital or other healthcare agency.
163. In addition to care related to the patient's basic needs, what other types of information does a comprehensive care plan contain? - Answer : :The comprehensive care plan also contains information about the medical/multidisciplinary plan of care, information about care related to nursing diagnoses and collaborative problems, and information regarding special teaching and/or discharge planning needs.
164. How are critical pathways different from other standardized care plans? - Answer : :Critical pathways focus on care for a particular medical diagnosis or DRG; they are organized on a timeline to meet recommended lengths of stay; instructions for nursing interventions are usually less specific/detailed.
165. What is the main disadvantage of computerized and standardized care plans? - Answer : :Computerized and standardized care plans may cause you to lose some creativity, intuition, insight, or caring because it is tempting, when you are busy, to accept the "easy Answer :" provided by the computer and not go further to think about the unique needs of this particular patient.
166. Figure 5-4 in Volume 1, a patient plan of care for Acute Pain, uses NOC language.

167. ● What outcomes did the nurse choose for this patient? - Answer : :● Pain Control Behavior
168. ● Pain Level
169. List two indicators for each of the outcomes. - Answer : :● Pain Control Behavior
170. ● Recognizes causal factors
171. ● Uses non-analgesic relief measures
172. ● Uses analgesics appropriately
173. ● Reports pain controlled
174. ● Pain Level
175. ● Oral/facial expressions of pain
176. ● Change in respiratory rate, heart rate, blood pressure
177. ● Restlessness
178. For which outcome does the nurse expect the highest level of functioning to occur after interventions? (Note that in this care plan the measuring scale has been applied to the outcomes rather than to the indicators.) - Answer : :Pain Control Behavior
179. Rationale:
180. It has higher numbers than Pain Level.
181. List at least eight questions you could use to critically evaluate the quality of your goal/outcome statements. - Answer : :Questions to ask include the following:
182. ● For each nursing diagnosis: Is there at least one goal that, when met, would demonstrate problem resolution? That is, does at least one goal flow from the problem clause?
183. ● For each nursing diagnosis: Are the predicted outcomes adequate to completely address the nursing diagnosis?
184. ● For each expected outcome:

185. ● Is the outcome appropriate for the nursing diagnosis?
186. ● Is each outcome derived from only one nursing diagnosis?
187. ● Does each outcome describe only one patient response or behavior?
188. ● Is the outcome stated as a patient behavior, not a nurse activity?
189. ● Is the outcome stated in positive, rather than negative, terms?
190. ● Is the outcome measurable or observable?
191. ● Are the performance criteria specific and concrete? Avoid words like normal, sufficient, enough, more, less, adequate, increased.
192. ● Does each goal include all the necessary parts?
193. ● Is the expected outcome realistic and achievable by this patient, given the available resources?
194. ● Does the outcome conflict with the medical or other collaborative treatment plan?
195. ● Does the patient, family, or community value the outcome?
196. ● Does the goal conflict with any religious or cultural values?
197. What is the body's most usable energy source - Answer : :Carbohydrates, especially glucose, provide the most usable energy.
198. Which nutrient's primary function is growth and repair of tissue? - Answer : :The primary function of dietary protein is the growth and repair of body tissues. Secondarily, proteins attract water in the bloodstream and contribute to regulating fluid-balance in the body. They function as buffers for regulating acid-base balance. Proteins are a secondary energy source. They are also involved in immune defense.
199. Identify five functions of adipose tissue (body fat). - Answer : : Answer :s may include any of the following functions of body fat:
200. ● Energy supply
201. ● Thermal insulation
202. ● Vital organ protection

203. ● Nerve impulse transmission
204. ● Tissue membrane structure
205. ● Cell metabolism
206. ● Essential precursor substances
207. ● Which type of vitamin requires daily consumption to maintain appropriate levels? - Answer : :Water-soluble vitamins require daily intake because they are eliminated in the urine with little storage in the body.
208. ● What distinguishes a major mineral from a trace mineral? - Answer : :Major minerals are those needed in amounts of 100 mg or greater per day. Trace minerals are essential, but needed in lower amounts.
209. ● Identify at least four functions of water. - Answer : :Water has the following functions:
210. ● Solvent. Water is the basic solvent for the body's chemical processes, assisting in the regulation of nerve impulses and muscle contractions.
211. ● Transport. Circulating as blood, water serves a medium for transporting oxygen, nutrients, and metabolic wastes.
212. ● Body structure and form. Water "fills in the spaces" in body tissues (e.g., in muscle) providing structure and form to the body.
213. ● Temperature. Water helps maintain body temperature and creates the necessary environment and temperature for cellular metabolism to occur. When body temperature rises, evaporation of sweat helps cool the body.
214. ● List at least three nutrients that may be more difficult to supply with a vegetarian diet. - Answer : :Nutrients more difficult to supply with a vegetarian diet are vitamin B12, protein, calcium, iron, zinc, and vitamin D. Vegans must supplement these nutrients and calcium or consume foods fortified with them.

215. ● When selecting a program for weight loss, what factors should a person consider? - Answer : :One should consider whether a diet is nutritionally and scientifically sound. For example, is it recommended by a respected organization, or is it a fad diet? Moderate calorie-restriction diets such as the American Heart Association diet describe food selection and preparation tips and other behavior modifications that can lead to slow, sustained weight loss, promote a diet that includes a variety of food choices and a balance of nutrients, and encourage physical activity as a cornerstone of weight loss. In contrast, fad diets often promise quick and dramatic weight loss, limit the range of foods from which the dieter can select, often recommend consuming supplements and/or specialized packaged meals, or include no practical strategies that help dieters permanently change eating and activity patterns.
216. ● Why should you encourage clients from various cultures to follow their traditional diets? - Answer : :Traditional diets of many cultures are healthy and honor and respect family or cultural traditions. Adaptations made to these diets have compromised the nutritional quality.
217. ● Describe the effects on nutrition of (a) smoking and (b) heavy alcohol use. - Answer : :The effects on nutrition are as follows:
218. ● Smoking. Smokers use Vitamin C faster than nonsmokers. Even children exposed to secondhand smoke tend to have lower plasma levels of ascorbate than unexposed children (Aghdassi, Royall, & Allard, 1999; Preston, 2003). If the person cannot quit smoking, a vitamin C supplement may help compensate.
219. ● Alcohol. A 12-oz beer contains 150 kcal; a juice-based cocktail contains about 160 kcal. Such drinks can add many unnecessary calories to the regular diet. In addition, alcohol significantly decreases the rate of fat metabolism, contributing to obesity. Excessive alcohol use interferes with adequate nutrition by (a) replacing the food in the person's diet, (b) depressing the appetite, (c) decreasing the absorption of nutrients by its toxic effects on

intestinal mucosa, and (d) impairing the storage of nutrients. People who use alcohol heavily will need multivitamin supplements, especially rich in B vitamins and folic acid.

220. ● Identify at least 10 physical examination findings that would lead you to suspect nutritional problems. - Answer : : Answer :s may include any of the following examination findings:
221. ● An increase in temperature
222. ● An elevated BP may be related to fluid volume excess; a low BP may be a sign of dehydration. Heart rate usually responds in an inverse fashion.
223. ● A BMI less than18 or greater than
224. ● An appearance of illness
225. ● Poor skin turgor
226. ● Poor wound healing
227. ● Constipation
228. ● Any areas of warmth or erythema require investigation
229. ● Red, swollen skin lesions, excessive bleeding and xerosis
230. ● Abnormal nail findings
231. ● Hair that grows slowly, is thin, or easily breaks
232. ● Irritation of the mouth, teeth, and gums
233. ● Facial paralysis or drooping of one side of the face
234. ● An enlarged thyroid gland
235. ● Bounding pulses or a weak, thready pulse
236. ● Edema
237. ● An abdomen that is scaphoid or concave, round to protuberant, or generally enlarged
238. ● Hyperactive or hypoactive bowel sounds
239. ● Thin extremities with excess skinfolds

240. ● Enlarged skinfold measurements
241. ● Joint swelling, deformities, or limitation in range of motion
242. ● Joint pain on palpation or with movement
243. ● Cognitive deficits or severe psychiatric disorders
244. ● Motor or sensory deficits
245. ● Confusion, weakness, or diminished reflexes
246. ● What factors would lead to poor wound healing? - Answer : :Factors contributing to diminished healing are insufficient intake of protein, vitamin C, and zinc.
247. ● When is enteral nutrition the preferred alternative feeding? - Answer : :Enteral nutrition is the preferred method of feeding for a patient with a functioning intestinal tract who is unable to meet his nutritional needs through oral intake.
248. ● Identify and describe the types of enteral nutrition tubes. - Answer : :● A nasogastric (NG) tube terminates in the stomach.
249. ● A nasoenteric (NE) tube terminates in the small intestine.
250. ● A gastrostomy tube (G-tube), percutaneous gastrostomy tube (PEG) tube, jejunostomy tube, or G-button is inserted into the stomach or jejunum, respectively, through the skin and abdominal wall.
251. ● A percutaneous jejunostomy (PEJ) tube is inserted into the stomach through the abdominal wall and advanced into the jejunum.
252. ● List four tube placement verification techniques. - Answer : :Tube placement can be verified by the following techniques:
253. ● Radiography, which is the most reliable method
254. ● Aspiration of contents and inspection for color
255. ● Measuring the pH of the aspirate
256. ● Injecting air into the tube while auscultating the stomach ("whoosh test")

257. ● Serial observations and assessments. These include observing for respiratory distress, inspecting aspirate for color and consistency, measuring the residual volume of the aspirate, and measuring the tube that extends outside of the body.
258. ● When observing for respiratory distress you might note difficulty breathing, coughing, choking, or cyanosis. Absence of these symptoms is not a reliable indicator of correct placement, but the presence of these symptoms is a strong indicator that the tube is in the respiratory tract.
259. ● Inspecting the aspirate may help distinguish placement through observation of a brown, white, or greenish color and curdled consistency for gastric contents and a more yellow (bile) color with no curdling for intestinal contents.
260. ● When evaluating residual volumes, note that gastric volumes will generally be larger than intestinal or esophageal volumes.
261. ● If the tube is not well secured, it may migrate either up or down, and so a consistent measurement of the external tube may also help verify tube placement (Peter & Gill, 2009).
262. ● Other bedside verification methods. Capnometry and additional tests of gastric juices may also serve as measures to ensure that the tube is correctly placed.
263. ● Capnometry tests for carbon dioxide (CO2). The presence of CO2 with the placement of an NG or NE tube would indicate that the tube has been placed in the respiratory tract. This method is best used at the time of tube placement. For a photo of a CO2 detector
264. Go to Chapter 26, Figure 26-12 , in Volume 1.
265. ● Measuring biliru

266. Review problem status (actual, potential, or possible nursing diagnosis; collaborative problem; or wellness diagnosis) in Chapter 4. For which type(s) of problem would you write:

- Answer : :● Nursing orders for observation/assessments? 

267. Answer ::
268. All problems
269. ● Nursing orders for treatments?
270. Answer ::
271. Primarily for actual nursing diagnoses and collaborative problems
272. ● Nursing orders for health promotion interventions?
273. Answer ::
274. Wellness diagnoses
275. ● Preventive nursing orders?
276. Answer ::
277. Actual and potential nursing diagnoses and collaborative problems
278. Describe a five-step process for generating and choosing nursing interventions. - Answer : :1. Review the nursing diagnosis. Nursing orders should flow from the etiology and sometimes from the problem side of the diagnosis.
279. 2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient.

280. 3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis.
281. 4. Choose the best interventions for this patient—those expected to be most effective in helping to achieve client goals.
282. 5. Individualize the standardized interventions to meet the unique needs of the patient.
283. List the five components of a nursing order. - Answer : :Date, subject, action verb, times and limits, signature
284. ● What is a normal defecation pattern? - Answer : :There is a wide range of "normal." The frequency of BMs may range from several times per day to once per week. Bowel function may be regarded as normal as long as stools are passed without excessive urgency (needing to rush to the toilet), with minimal effort and no straining, without blood loss, and without the use of laxatives.
285. ● Identify the factors that affect bowel elimination. - Answer : :The following factors affect bowel elimination:
286. ● Age
287. ● Stress
288. ● Dietary intake
289. ● Fluid intake
290. ● Activity
291. ● Medications
292. ● Surgery
293. ● Anesthesia
294. ● Pregnancy
295. ● Pathological conditions (e.g., food allergies and intolerances, diverticulosis, diverticulitis)

296. ● What changes in bowel elimination are associated with constipation? With diarrhea? - Answer : :The following changes in bowel elimination are associated with these conditions:
297. ● Constipation is a decrease in frequency of BMs. As the length of time between BMs increases, more water is reabsorbed from the feces. As a result, constipation is also associated with passage of dry, hard stool that requires more effort to pass.
298. ● Diarrhea is an increase in the frequency of BMs. As transit time through the colon decreases, less water is reabsorbed and stools are often watery.
299. ● Why are bowel diversions performed? - Answer : :A bowel diversion is a surgically created opening for elimination of digestive waste products from the bowel. This procedure is performed for clients with a variety of conditions, including cancer, ulcerations, trauma, or inadequate blood supply. Temporary diversions are performed to allow healing of the distal portion of the bowel; permanent diversions are performed in instances of severe disease or trauma when the bowel is necrotic or cannot be salvaged.
300. ● What determines the nature of the effluent from a bowel diversion? - Answer : :The effluent may range from liquid to solid depending on the part of the bowel that is being diverted. The lower in the bowel the colostomy is placed (i.e., the closer to the rectum and anus), the more solid the effluent. Because the fecal matter stays in the bowel longer, more water can be absorbed from it, and it becomes more solid.
301. ● What should you discuss with your client when performing a nursing history focused on bowel elimination? - Answer : :The following items should be part of a nursing history focused on bowel elimination:
302. ● Normal bowel pattern
303. ● Appearance of stool
304. ● Changes in bowel habits or stool appearance
305. ● History of elimination problems

306. ● Use of bowel elimination aids, including diet, exercise, medications, and remedies
307. For a list of questions that you may use to assess each of these areas, go to Chapter 28 of Volume 2, Assessment Guidelines and Tools, Focused Assessment: Bowel Elimination.
308. ● Describe the physical assessment you would perform for a client with constipation.

- Answer : :Physical assessment for bowel elimination includes examination of the abdomen, rectum, and anus. 

309. ● Recall that in abdominal assessment, the order of the exam is inspection, auscultation, percussion, and palpation.
310. ● Observe the size, shape, and contour of the abdomen, and listen to bowel sounds.
311. ● Percuss and palpate the abdomen for tenderness, presence of air or solid, and presence of masses.
312. ● Inspect the anus for signs of hemorrhoids.
313. ● Depending on the policies of your institution as well as your skill with assessment, you might also palpate the anus and rectum for the presence of stool or masses.
314. ● How can you help a patient adapt psychologically to living with a bowel diversion? - Answer : :The following nursing interventions help a patient adapt psychologically to a bowel diversion (other Answer :s are possible):
315. ● Being willing to talk with a patient about his reaction to the stoma and concerns about living with an ostomy
316. ● Taking a caring approach when providing stoma care
317. ● Allowing adequate time for the patient to learn about self-care
318. ● Coordinating a visit by a volunteer from the United Ostomy Association
319. ● Providing information about a community support group of people living with an ostomy or other bowel diversion