NURS 3605 - Exam 2 Questions With Complete Solutions
Abdominal Organs Correct Answers
Abdominal Quadrants Correct Answers listen to these when
seeking bowel sounds
Act of Urination Correct Answers Brain structure influences
bladder function (cerebral cortex, thymus, hypothalamus, brain
stem)
Voiding: bladder contraction + urethral sphincter and pelvic
floor muscle relaxation
1. bladder walls stretching signals micturition center.
2. impulses from the micturition center in the brain responds to
or ignore this urge, thus making urination under voluntary
control
3. when a person is ready to void, the CNS sends a message to
the micturition centers, the external sphincter relaxes and the
bladder empties
usually 400-600 mL before urge
Advancing Diets Correct Answers Advance as tolerated and
prescribed
Ice Chips --> clear liquid --> full liquid --> mechanical soft -->
soft --> regular (no restrictions)
Alternative Food Patterns Correct Answers Based on religion,
cultural background, ethics, health beliefs, and preference
,Examples:
- Vegetarian
- Vegan (no animal - deficient in vitamin B12 (animal))
- Zen Macrobiotic & Frutarian (very very nutrient poor and
children have died)
- Religion specific diets (do not assume they follow their
religious diet)
Areas at risk for pressure ulcers Correct Answers bony
prominences
heels/sacrum most common
Assessing Abdominal Pain Correct Answers - "my stomach
hurts" location: lower R quad
- quality: cramping
- Quantity: 4 on scale of 0-10
- Timing: Onset: 1 day Duration: 30 mins Freq: constant
- Setting: everywhere
- Aggravating and Reliving: worse on movement, nothing
relieved
- associated factors: nausea and fever
"I think I have appendicitis"
visceral: internal organ pain
referral: gallbladder goes out and feeling in shoulder blades
Assessment of Skin Correct Answers Overall Skin health
,Target ar risk areas - bony prominences, extremities
Identify risk factors
Tools: Braden Scale (through assessment when admitted)
- the lower the number, the higher the risk
- 18 or below = severe risk
- sensory perception, moisture, activity, mobility, nutrition,
friction or sheer
Assessment of Urine Correct Answers Intake and Output
Characteristics of urine
- color, clarity, odor
Bladder Assessment Correct Answers Urinary Retention
- inability to empty the bladder completely
- bladder unable to respond to micturition reflex
- patient may void 2-3x/hour without real relief
- may continually dribble urine
- may feel pressure in the bladder region
- with severe retention the bladder can hold 2-3L of urine (hard
to palpate in these cases)
- check residual (PVR) urine left in bladder post void using
bladder scanner (10 minutes after peeing)
Bowel Diagnostic Tests Correct Answers Lab
- CBC (hematocrit), Occult blood (blood in stool, carry this to
lab), Cultures (bacteria), O & P (parasites, also take down as
warm)
, Noninvasive Visual
- Radiology, MRI (structures), CT, Ultrasound
Invasive Visual
- EGD (down through third to stomach), Colonoscopy, Capsule
study (small monitor swallowed by patients and helpful with GI
bleeds)
Bowel Diversions Correct Answers can be temporary or
permanent
Stoma - should be pink/moist
Ileostomy - ascending - liquid with some stool
Colostomy
- any part of large intestine (location)
Psychological considerations
- serious problems/doubts
puncture wound, gunshot wound, need rest from bowel
movements
Bowel Elimination - Auscultation Correct Answers 2nd step!!!
Normoactive - every 5-15 seconds
Hypoactive
Hyperactive - high pitched, IBD, diarrhea, overuse of laxatives
Absent - nothing, ileus, no bowel sounds
Abdominal Organs Correct Answers
Abdominal Quadrants Correct Answers listen to these when
seeking bowel sounds
Act of Urination Correct Answers Brain structure influences
bladder function (cerebral cortex, thymus, hypothalamus, brain
stem)
Voiding: bladder contraction + urethral sphincter and pelvic
floor muscle relaxation
1. bladder walls stretching signals micturition center.
2. impulses from the micturition center in the brain responds to
or ignore this urge, thus making urination under voluntary
control
3. when a person is ready to void, the CNS sends a message to
the micturition centers, the external sphincter relaxes and the
bladder empties
usually 400-600 mL before urge
Advancing Diets Correct Answers Advance as tolerated and
prescribed
Ice Chips --> clear liquid --> full liquid --> mechanical soft -->
soft --> regular (no restrictions)
Alternative Food Patterns Correct Answers Based on religion,
cultural background, ethics, health beliefs, and preference
,Examples:
- Vegetarian
- Vegan (no animal - deficient in vitamin B12 (animal))
- Zen Macrobiotic & Frutarian (very very nutrient poor and
children have died)
- Religion specific diets (do not assume they follow their
religious diet)
Areas at risk for pressure ulcers Correct Answers bony
prominences
heels/sacrum most common
Assessing Abdominal Pain Correct Answers - "my stomach
hurts" location: lower R quad
- quality: cramping
- Quantity: 4 on scale of 0-10
- Timing: Onset: 1 day Duration: 30 mins Freq: constant
- Setting: everywhere
- Aggravating and Reliving: worse on movement, nothing
relieved
- associated factors: nausea and fever
"I think I have appendicitis"
visceral: internal organ pain
referral: gallbladder goes out and feeling in shoulder blades
Assessment of Skin Correct Answers Overall Skin health
,Target ar risk areas - bony prominences, extremities
Identify risk factors
Tools: Braden Scale (through assessment when admitted)
- the lower the number, the higher the risk
- 18 or below = severe risk
- sensory perception, moisture, activity, mobility, nutrition,
friction or sheer
Assessment of Urine Correct Answers Intake and Output
Characteristics of urine
- color, clarity, odor
Bladder Assessment Correct Answers Urinary Retention
- inability to empty the bladder completely
- bladder unable to respond to micturition reflex
- patient may void 2-3x/hour without real relief
- may continually dribble urine
- may feel pressure in the bladder region
- with severe retention the bladder can hold 2-3L of urine (hard
to palpate in these cases)
- check residual (PVR) urine left in bladder post void using
bladder scanner (10 minutes after peeing)
Bowel Diagnostic Tests Correct Answers Lab
- CBC (hematocrit), Occult blood (blood in stool, carry this to
lab), Cultures (bacteria), O & P (parasites, also take down as
warm)
, Noninvasive Visual
- Radiology, MRI (structures), CT, Ultrasound
Invasive Visual
- EGD (down through third to stomach), Colonoscopy, Capsule
study (small monitor swallowed by patients and helpful with GI
bleeds)
Bowel Diversions Correct Answers can be temporary or
permanent
Stoma - should be pink/moist
Ileostomy - ascending - liquid with some stool
Colostomy
- any part of large intestine (location)
Psychological considerations
- serious problems/doubts
puncture wound, gunshot wound, need rest from bowel
movements
Bowel Elimination - Auscultation Correct Answers 2nd step!!!
Normoactive - every 5-15 seconds
Hypoactive
Hyperactive - high pitched, IBD, diarrhea, overuse of laxatives
Absent - nothing, ileus, no bowel sounds
