NURS 108 - Exam #2 QUESTIONS AND ANSWERS

NURS 108 - Exam #2 QUESTIONS AND ANSWERS Module 10 - Identify client potential for skin breakdown (e.g., immobility, nutritional status, incontinence). - CORRECT ANSWER-1. Agerelated variations: young and old. 2. Impaired mobility: caused by conditions that require complete bed rest or that seriously limit activity. 3. Nutrition and Hydration: adequate intake of protein, cholesterol, calories, fluid, vitamin C, and minerals is essential. 4. Diminished sensation or cognition: patients with PVD, spinal cord injury, diabetes, CVA, trauma, or fractures often have diminished tactile sense. Impaired cognition can be due to Alzheimer's disease, dementia, or altered LOC. 5. Impaired circulation: venous and arterial. 6. Medications: any med that causes pruritus (itching), dermatoses (rashes), photosensitivity, alopecia, or pigmentation changes. 7. Moisture on the skin: urine and bowel incontinence, fever. 8. Fever: sweating + increases metabolic rate. 9. Contamination or infection 10. Lifestyle: tanning, hygiene habits, regular exercise, nutritious diet, smoking, body piercings and tattoos. Module 10 - Identify complications of immobility (e.g., skin breakdown, contractures). - CORRECT ANSWER-~*Metabolic changes* - alter endocrine metabolism, calcium resorption, and the GI. Weight gain, negative nitrogen imbalance, constipation, decrease metabolic rate, calcium resorption ~*Respiratory changes* - lack of movementplaces patients at risk for respiratory complications like atelectasis, pneumonia, decreased oxygenation ~*Cardiovascular chnages* - increased caridac workload, thrombus formation, hypotension, decreased circulating blood, clotting ~*Musculoskeletal changes* - resticted mobillity can result in loss of enderance, strength, stability, balance, and muslce mass. osteoporsis, contracture, footdrop, decreased bone mass ~*Urinary elimination chnages* - when a patient is flat and not standing as much the kidneys move more toward a level plane. Urinary stasis, renal calculi, incontinence, decreased fluid intake/output ~*Integumentary chnages* - immobility puts more pressure on the skin and can cause pressure ulcers, decrease in tissue circulation ~*Psychosocial changes* - emotional and behaviroal responses, sensory alterations, changes in coping, depression, increase worrying