MDC 1 - Exam 2 Study Guide Questions With Correct Answers.

MDC 1 - Exam 2 Study Guide Questions With Correct Answers. - Always knock or announce your entrance into the patient's room or area and introduce yourself. - Orient the patient to the environment, counting steps with him or her to the bathroom - Help the patient place objects on the bedside table or in the bed and around the bed and room and do not move them without the patient's permission - Remove all objects and clutter between the patient's bed and the bathroom. - Use a normal tone of voice. What are some nursing interventions for visual impairment? anisocoria a condition in which the pupils are unequal in size exophthalmos protrusion of the eyeballs, as seen in Graves disease enophthalmos sunken eyes, eyeballs are recessed ptosis prolapse, downward displacement, dropping - Put in lower conjunctival sac - Do not drop in center of eye - Stabilize hands on facial structures (bony prominences) - Hold the inner eye to avoid systemic effects (punctal occlusion) - Do not let dropper touch their eye - Wash hands before Patient education for instilling eye drops punctal occlusion Drainage of topical drops from the eye and their systemic absorption can be prevented by _________ _________? · Blurred vision · Clouded vision · Decreased color perception · May think that glasses are smudged · Double vision · Halos around objects · Problems with ADL'S · Affects reading and driving · Impaired night vision · Frequents changes in eyeglass prescription · Without surgical intervention blindness follows Signs and symptoms of cataracts · Wear dark glasses and avoid bright sunlight · Do not drive · Develop a schedule for the administration of post-op eye drops. Be sure client or family can demonstrate the correct technique for administering the drops. · Report Worsening Vision · Observe for increasing eye redness · Decrease in vision · Floaters · Sharp, or sudden pain in eye · Green or yellow drainage on the lids and lashes ***avoid anything that increases IOP like... · Do no bend at the waist · Lift more than 10 pounds · Sneeze or cough · Blow your nose · Strain to move bowels · Have sexual intercourse · Vomit · Keep head in a dependent position · Wear tight shirt collars Patient Education for post-op cataract surgery glaucoma When the intraocular pressure increases it leads to compression of the retinal blood vessels and photoreceptors and their nerve fibers resulting in hypoxemia and death of the tissue and permanent loss of vision - Sudden severe pain around the eyes radiating over the face - Headache or brow pain - Nausea and vomiting - Seeing colored halos around lights - Sudden blurred vision - Reddened sclera - Foggy cornea - Moderately dilated pupil that does not react to light - Cupping and atrophy of the optic disc Signs and symptoms of glaucoma 10 mm Hg - 21 mm Hg What is the normal intraocular range pressure? reduce intraocular pressure What is the goal of treatment for glaucoma? tonometry - measures IOP ultrasonic imaging of the retina and optic nerve - creates a three-dimensional view of the back of the eye; tells us the TYPE of glaucoma How do you test for glaucoma? corneal staining dye outlines irregularities of corneal surface (used for corneal trauma, problems caused by contacts, or presence of foreign bodies, abrasions, ulcers, or other corneal disorders). Assess vital signs (specifically BP and P) These drugs (like timolol) potentiate the effects of systemic beta blockers and can cause an unsafe drop-in heart rate and blood pressure Before administering eye drops, what must the nurse assess and why? Meniere's disease Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears). Patient should not drive Can be intermittent. Cause is unknown/genetic Can be dangerous to patient (fall risk!) ***build-up of fluids - Turn head slowly - Stop smoking - Reduce sodium intake (so less fluid buildup/pressure) - Use medications as directed Patient education for Meniere's disease monitor vital signs Post surgical care for tympanoplasty Weber test The ________ test is performed by placing a vibrating tuning fork on the middle of the patient's head and asking him or her to indicate in which ear the sound is louder. Sound heard equally in both ears What are normal results of the Weber test? systolic (90-120) diastolic (60-80) Normal blood pressure ranges for systolic and diastolic 60-100 bpm Normal pulse range Temperature (96.4-99.5 F) - Oral (98.6 F) - Tympanic (99.6 F) - Rectal (99.6 F) - Axillary (97.6 F) Normal temperature ranges per thermometer type 12-20 bpm Normal respiratory rate range 94%-100% Normal pulse oximetry range - spread your feet far apart to lower the center of gravity - lifting an object from the floor, flex your hips, knees, and back. - bring the object to thigh level, bending your knees and keeping your back straight. - stand up while holding the object as close as possible to your body, bringing the load to the center of gravity to increase stability and decrease back strain. - face the direction of movement *ATI Ch. 14 p.73-76 How does a nurse maintain balance and body posture when lifting? to stretch (before and after exercise) to promote ROM Patient education for flexibility · Improves pulmonary circulation (keeping the tissue well oxygenated, healthy, and elastic.) · Improves gas exchange at the alveolar-capillary membrane, and overall aerobic capacity. · Dilates bronchioles to increase ventilation/gas exchange. What are the benefits of regular exercise on the Respiratory System? · Improves skeletal development in children.***** · Increases muscle mass, strength, power, and endurance. · Improves flexibility. · Increases coordination. · Helps maintain joint structure and function; reduces risk of osteoarthritis. · Improves bone mass and mineral density.***important for our older patients · Improves gait speed, stability, and balance. · Facilitates weight management. · Decreases adipose surrounding organs. What are the benefits of regular exercise on the Musculoskeletal System? · Improves appetite. · Improves abdominal muscle tone. · Decreases risk of colon cancer. · Walking increases peristalsis*** What are the benefits of regular exercise on the Gastrointestinal System? · Improves skin tone as a result of improved circulation (so improved turnover of skin cells). What are the benefits of regular exercise on the Integumentary System? · Reduces susceptibility to minor viral illnesses. · Reduces systemic inflammation. · Improves bone mass with aging; reduces risk of osteoporosis. · Reduces risk of falls and helps older adults maintain an independent lifestyle. · Important for patients with an inflammatory disorder*** What are the benefits of regular exercise on the Immune System? · Boosts energy level. · Release endorphins, which assist with pain control and stress management. · Improves self-esteem and body image. · Provides a nonpharmacological way to relieve symptoms of anxiety and depression. · Leads to positive outlook and sense of optimism. · Promotes clearer thinking and improved memory in older adults. · Enhances feelings of well-being and diminishes depressive symptoms. · Relieves some stress. · Can be a source of social interaction. What are the benefits of regular exercise on Mental Health? 45-60 degrees What degree is the headrest for Fowler's Position? 30-45 degrees What degree is the headrest for Semi-Fowler's Position? 60-90 degrees What degree is the headrest for High-Fowler's Position? High Fowler's Position What position would you set the bed for a patient that is having trouble breathing? Supine (totally flat) What position would you set the bed for a patient that has low BP? Use a friction-reducing device to move the patient if the patient can assist with movement. Use a full body sling if the patient cannot assist. Remove the pillow. Have the patient flex her neck, fold her arms across her chest, and place her feet flat on the bed. Position a nurse on either side of the patient. Use a wide base of support. Have the patient, on the count of 3, push off with his heels as you shift your weight forward What do we instruct the patient to do when we are moving them off the bed? - increases workload of the heart - venous stasis (leads to DVT) p. 831 Funds book What are the effects of immobility on the Circulatory System?