Nursing Interventions for Urinary Incontinence and Fall Prevention, Exams of Nursing

Download Nursing Interventions for Urinary Incontinence and Fall Prevention and more Exams Nursing in PDF only on Docsity! MULTIDIMENSIONAL CARE I – PREP EXAM Questions and Answers Latest Update 2024 GRADED A+ B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. - ANSWER A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine. A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catheterization - ANSWER A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization B. Decrease or avoid caffeine. D. Avoid drinking alcohol. - ANSWER A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver A. Guided imagery C. Meditation D. Music therapy - ANSWER A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (Select all that apply.) A. Guided imagery of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room. -R- Rescue and remove all patients in immediate danger. -A- Activate the alarm. -C- Confine the fire by closing doors and windows and turning off oxygen and electrical equipment; ventilate patients who are on life support with a bag-valve mask -E- Extinguish the fire using an appropriate extinguisher - ANSWER Fire response follows the RACE sequence, what does each letter stand for? P - pull the pin A - aim at the base of the fire S - squeeze the handle S - sweep the extinguisher from side to side covering the area of the fire - ANSWER To use a fire extinguisher, use the PASS sequence, what does each letter stand for? 1. complete a fall-risk assessment at admission & regular intervals 2. ensure patient has and knows how to use the call light 3. use fall-risk alerts (color-coded wristbands) 4. provide regular toileting and orientation of clients who have cognitive impairment 5. provide adequate lighting 6. place clients at risk for falls near a nurses station 7. provide hourly rounding 8. make sure personal items are within reach 9. keep bed low, lock the breaks 10. side rails up (for unconscious patients, sedated, etc.) 11. non-skid footwear 12. use gait belts and other assistive equipment when moving patients 13. keep floor clean (no clutter, cords, scatter rugs, etc.) 14. electronic safety monitors (chair or bed sensors) - ANSWER Name some nursing interventions of PREVENTING FALLS That nurses respond in a timely manner...otherwise the patient may become impatient and attempt to move themselves - ANSWER What is a nurse's concern with patients using their call lights? primary survey - ANSWER What must be completed before performing first aid? - apply pressure to wound site (home) - DO NOT remove impaling objects, stabilize the object (home) - IV volume replacement with blood or volume replacement (hospital) - ANSWER Name the nursing interventions for BLEEDING R - refrain from weight bearing (also known as "rest") I - apply ice to decrease inflammation C - apply a compression dressing to minimalize swelling E - elevate the affected limb - ANSWER The acronym RICE is used to manage sprains, what do the letters stand for? - remove the agent - smooth any flames present - cover the client and maintain NPO status - elevate the extremities - Stop, Drop, and Roll (home) - call 911 (home) - perform H to T assessment (hospital) - administer fluids and tetanus toxoid (hospital) - ANSWER Name the nursing interventions for BURNS A. Hypotension - ANSWER A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - place infants on back to rest - never leave alone in bathtub - do not place anything in the crib; remove mobiles when baby can sit up - keep latex balloons away - toilet lids down, bathroom doors closed - make sure slats on crib are a safe distance - ANSWER Name the nursing interventions of INFANT SUFFOCATION - avoid tobacco, alcohol, caffeine - ANSWER What are the dietary considerations for Mormons? - provide language assistance - informing clients of language services verbally and in writing - providing competent, trained interpereters - giving the client learning materials - ANSWER Name the nursing interventions for CULTURALLY RESPONSIVE CARE B. Determine client understanding several times during the conversation D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk - ANSWER A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk. C. The same religious beliefs can influence individuals differently. - ANSWER A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs. C. Ensure no visitors or staff enter the room for a short time period - ANSWER A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services. B. Ask what is making the client cry. C. Ensure no visitors or staff enter the room for a short time period. D. Turn on the television for a distraction. B. "I will ask the client if they want to schedule some times to pray during the day" - ANSWER A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client." D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." - ANSWER A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? - maintain skin integrity - relieve discomfort - prevent transmission of micro organisms (catheter care) - ANSWER Name some benefits of perineal care - inspect daily - use lukewarm water, and dry feet thoroughly - apply moisturizer - avoid over-the-counter meds with alcohol or other strong chemicals - clean socks - check shoes for objects, rough seams, or edges - cut nails straight across - avoid self-treating corns or calluses - do not apply heat - ANSWER Name some patient education for foot care narcolepsy - ANSWER sudden attacks of sleep that are often uncontrollable often happens at inappropriate times and increases the risk of injury - exercise regularly - eat small meals that are high in protein - avoid activities that increase sleepiness (sitting too long, warm environments, drinking alcohol) - avoid activities that could cause injury to the client should they fall asleep (heights, driving) - take naps - take prescribed simulants - ANSWER Patient education for Narcolepsy - Physiologic disorders: can require more sleep or disrupt sleep (sleep apnea, nocturia) - Current life events: traveling more, change in work hours - Emotional stress or Mental illness: anxiety, fear, grief - Diet: caffeine, heavy meals before bedtime - Exercise: promotes sleep if at least 2 hour before bedtime, otherwise can disrupt sleep - Fatigue: exhausting or stressful work makes falling asleep difficult - Sleep environment: too light, the wrong temperature, or too noisy - Medications: some can induce sleep but interfere with restorative sleep. Others cause insomnia (bronchodilators, antihypertensives) - Substance use: nicotine and caffeine are simulants, caffeine and alcohol tend to cause night awakenings - ANSWER Factors that interfere with sleep A. Turn the client's head to the side - ANSWER A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth. A. Inspect the feet daily B. Use moisturizing lotion on the feet E. Wear cotton socks - ANSWER A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions. E. Wear cotton socks A. Face - ANSWER A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms B. Brush the dentures with a toothbrush and denture cleaner - ANSWER A nurse is preparing to perform denture the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication. B. "I'll take a short nap whenever I feel a little sleepy." - ANSWER A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day." - turn patient every 2 hours - ROM exercises - check for sores (redness) - pad bony prominences - ANSWER Name some nursing actions for immobility C. Pressure injury - ANSWER A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction A. Encourage the client to perform antiembolic exercises every 2 hr. - ANSWER A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr. Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints, wedge pillows) - ANSWER When you see indications of skin breakdown, what is your next action? Palliative/Provoking Quality Region/Radiation Severity Timing - ANSWER What does PQRST stand for? - grimacing - moaning - flinching - guarding - decreased attention span - restlessness, pacing - ANSWER What are some nonverbal signs of pain? - BP increased - Pulse increased - RR increased - ANSWER What do vital signs look like during acute pain? - drug interactions - allergies - vital signs - side effects - cognitive behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort - cutaneous stimulation: cold, heat, therapeutic touch, massage, TENS - distraction: ambulation, deep breathing, visitors, television, games, prayer, music - relaxation: yoga, meditation, progressive muscle relaxation - imagery: pleasant thought, ability to concentrate - acupuncture/acupressure - elevation of edematous extremities - ANSWER Non-Pharmacological Pain Management strategies wound healing - ANSWER What does Aloe promote? anti-inflammatory, calming - ANSWER What does chamomile promote? enhances immunity - ANSWER What does echinacea promote? inhibits platelet aggregation (clumping) - ANSWER What does garlic promote? antiemetic (prevents N/V) - ANSWER What does ginger promote? improves memory - ANSWER What does ginko biloba promote? increases physical endurance - ANSWER What does ginseng promote? Promotes sleep, reduces anxiety - ANSWER What does valerian promote? complementary therapy - ANSWER A variety of therapeutic or preventive health care practices, such as homeopathy, naturopathy, chiropractic, and herbal medicine, that do not follow generally accepted medical methods and may not have a scientific explanation for their effectiveness. used in addition to or to enhance conventional medical care alternative therapy - ANSWER includes herbs and other "natural" products as often found in ancient records; these products are not controlled or tested by the U.S. Food and Drug Administration and are considered to be dietary supplements; however, they are often the basis for discovery of an active ingredient that is later developed into a regulated medication treatment approaches that are used in addition to or to enhance conventional medical care A. Chamomile - ANSWER A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? A. Chamomile B. Ginseng C. Ginger D. Echinacea A. Offer information on a relaxation technique and ask the client if they are interested in trying it. - ANSWER A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. Offer information on a relaxation technique and ask the client if they are interested in trying it. B. Request a social worker see the client to discuss meditation. C. Attempt to use biofeedback techniques with the client. D. Tell the client many people feel the same way before surgery and to think of something else. UTIs - ANSWER Complications of urinary elimination - wipe front to back - pee before and after sex - cleanse beneath foreskin - provide catheter care regularly (nurses) - ANSWER UTI patient education A. Check to see whether the catheter is patent. - ANSWER A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? Independence Individuality Wealth Comfort Cleanliness Achievement Youth and beauty - ANSWER What are some Dominant Values among White or European American? Extended family Group emphasis Fatalistic Faith and spirituality - ANSWER What are some Dominant Values among Hispanic or Latino? Bonding to family or group Acceptance of nature (Mother Earth) Tradition Sharing Belief in a spiritual power Respect of elders - ANSWER What are some Dominant Values among Native Americans Extended family Respect for elders Group orientation Subordination to authority Conformity Self-respect and self-control Love of the land - ANSWER What are some Dominant Values among Asian and Pacific Islander Family bonding Matrifocal Spiritual orientation Present-oriented - ANSWER What are some Dominant values among Black and African Americans? Direct eye contact Concerned facial expression Leaning forward Personal space Professional appearance Sitting down to talk Touch - ANSWER Name some enhancing nonverbal cues Pre-interaction Orientation Working Termination - ANSWER Stages of Therapeutic Communication Pre-interaction phase - ANSWER Name this stage of Therapeutic Communication: - Even before you meet the client, this phase is established. - You begin establishing communication by gathering information about the client, but the nurse and client do not have direct communication. orientation phase - ANSWER Name this stage of Therapeutic Communication: - The phase begins when you meet the client and introduce yourself and your role in the relationship. - The goal of this phase is to establish rapport and trust through the use of verbal and nonverbal communication. working phase - ANSWER Name this stage of Therapeutic Communication: - The bulk of therapeutic communication occurs in this phase - During this phase, the nurse communicates caring, the patient expresses thoughts and feelings, mutual respect is maintained, and honest verbal and nonverbal expression occurs. termination phase - ANSWER Name this stage of Therapeutic Communication: - The conclusion of the relationship, whether at the end of the nurse's shift or on the client's discharge from the unit, facility, or service. - Reviewing and summarizing help to bring the relationship to a comfortable conclusion. empathy P - pay attention to the care you are receiving E - educate yourself about your diagnosis A - ask a trusted friend or family member to be your advocate K - know your medications and why you take them U - use a hospital, clinic, surgery center, or other type of healthcare organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission P - participate in all decisions about your treatment - ANSWER What does the SPEAKUP acronym stand for? Joint Commission - ANSWER Who wrote the National Patient Safety Goals? - ANSWER What is the purpose of the National Patient Safety Goals never events - ANSWER serious but preventable errors (that should never occur) ex: falls, UTIs from catheters, foreign object, air embolism, administering the wrong type of blood, severe pressure ulcers, injuries from burns, restraints, or bed rails, infections with IVs, DVT, etc. National Patient Safety Goals (NPSGs) - ANSWER Goals issued by the Joint Commission to improve patient safety in healthcare organizations nationwide Occupational Safety and Health Administration - ANSWER What does OSHA stand for? to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance. - ANSWER What is OSHA's purpose? incident report - ANSWER a means of documenting problem events within a hospital or other medical facility read p. 548 in Fundamentals book - ANSWER POISONING???? ADPIE Assessment Diagnosis Planning Intervention Evaluation - ANSWER Steps of the Nursing Process systematic collection, organization, validation, and documentation of patient data - ANSWER What happens during the Assessment phase of the Nursing Process? The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs. - ANSWER What happens during the Diagnosis phase of the Nursing Process? - the nurse sets measurable and achievable short- and long-range goals for this patient. - Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. - ANSWER What happens during the Planning phase of the Nursing Process? - activities or actions that a nurse performs to achieve client goals. - Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. - ANSWER What happens during the Intervention phase of the Nursing Process? - to determine whether, after application of the nursing process, the client's condition or well-being improves. - The nurse conducts evaluation measures to determine if expected outcomes are met, not the nursing interventions. - ANSWER What happens during the Evaluation phase of the Nursing Process? 12-20 breaths per minute - ANSWER normal respiratory rate 120/80... Systolic: 90-120 Diastolic: 60-80 - ANSWER Normal range for BP 96.4 -99.5 degrees Fahrenheit Oral: 98.6 Tympanic: 99.6 Rectal: 99.6 Axillary: 97.6 - ANSWER Normal range for temperature