NSE 111 FINAL EXAM QUESTIONS
WITH COMPLETE SOLUTIONS
(GRADED A+)
What are some examples of alternatives to restraints? - Answer- - providing
companionship & supervision
- offering distractions
- using deescalation
- etc
restraint use should be done based on the needs of the _________, not the ________ -
Answer- patient, staff
what are physical restraints? examples? - Answer- - limits a patient's movement
- can be attached to their body or a barrier
- e.g. bed rails, wrist restraints
what are the three types of restraints? - Answer- physical, chemical, environmental
what are chemical restraints? examples? - Answer- "any form of psychoactive
medication used not to treat illness but to inhibit a behaviour/movement"
- e.g. sedatives, tranquilizers
what are environmental restraints? example? - Answer- modifications of an individual's
surroundings that control their mobility
- e.g. a locked unit
what are the objectives of restraints? - Answer- - protect from injury
- protect others from injury
- maintain treatment
what are some potential complications of restraints? - Answer- - increased risk of falls
- pressure injuries
- contractures
- psychological impacts
- etc
what are the three nursing responsibilities when using restraints? - Answer- -
assessment should be ongoing
- proper documentation
,- should actively involve patient, family, & healthcare team
what should be assessed prior to planning client's elimination needs? - Answer- - health
history (usual patterns, symptoms, etc)
- physical assessment (skin integrity? organ related to voiding's condition?)
what factors can affect urinary elimination? - Answer- - psychological
- sociocultural
- fluid balance
- surgical procedures
- pathological conditions
- medications
what factors can affect bowel elimination? - Answer- - age-related changes
- infectious disease (e.g. norovirus)
- IBS or IBD
- diabetes
- pain
- pelvic floor trauma
- acute illnesses, medications
what age-related changes affect bowel elimination? - Answer- older persons are at a
higher risk of incontinence, constipation due to changes in muscle tone & slowing of
nerve impulses
what is urination? other names? - Answer- the process of emptying the bladder; also
known as micturition, voiding
what is urinary incontinence? why does it occur? - Answer- "an involuntary loss of urine"
due to pelvic lack of muscle strength, control of the bladder and structural damage
what is urinary retention? - Answer- inability to empty the bladder
what are signs of urinary retention? - Answer- - absence of urinary output
- bladder distention
- pain, discomfort
what is defecation? - Answer- elimination of wastes & undigested foods in the form of
feces from the rectum
what is bowel incontinence? - Answer- involuntary passage of feces and gas from the
anus
what are contributing factors to bowel incontinence? - Answer- - diet
- fluid intake
- alcohol
, - nicotine
risks for bowel incontinence? - Answer- - lack of cognitive awareness
- conditions that result in frequent large loose stools
what is flatulence? - Answer- accumulation of gas in the intestines causing the walls to
stretch, resulting in gas passing through the anus
what are signs of constipation? - Answer- - Infrequent bowel movements (less than 3
per week)
- Hard, dry stools that are difficult to pass
- abdominal pain, fullness
what is diarrhea? - Answer- an increase in the number of stools and the passage of
liquid, unformed feces
how can you measure urine output? - Answer- from drainage bag or urine hats
how can you measure urine input? - Answer- measuring what fluids enter the body
during meals or through IV
abnormal urine output? - Answer- - less than 30ml per hour for 2 hours
- <2000-2500 daily
what are normal and abnormal urine colours? - Answer- normal = range from pale straw
to amber
abnormal = red, orange, dark amber
what are normal and abnormal urine clarity levels? - Answer- normal = transparent at
voiding, can become cloudy if left standing
abnormal = cloudy/foamy, thick
what are abnormal urine smells? - Answer- sweet = diabetes or starvation
ammonia = stagnant urine
what are interventions to promote normal micturition? - Answer- - patient education
- promote regular urinary habits (i.e. try not to void too frequently)
- promote complete bladder emptying
- using positions or stimulating the micturition reflex
what are interventions to promote normal bowel elimination? - Answer- - positioning
- ensuring comfort & safety
- address factors that can impact defecation
- ensure adequate fluid intake
- promote physical activity
- medications
WITH COMPLETE SOLUTIONS
(GRADED A+)
What are some examples of alternatives to restraints? - Answer- - providing
companionship & supervision
- offering distractions
- using deescalation
- etc
restraint use should be done based on the needs of the _________, not the ________ -
Answer- patient, staff
what are physical restraints? examples? - Answer- - limits a patient's movement
- can be attached to their body or a barrier
- e.g. bed rails, wrist restraints
what are the three types of restraints? - Answer- physical, chemical, environmental
what are chemical restraints? examples? - Answer- "any form of psychoactive
medication used not to treat illness but to inhibit a behaviour/movement"
- e.g. sedatives, tranquilizers
what are environmental restraints? example? - Answer- modifications of an individual's
surroundings that control their mobility
- e.g. a locked unit
what are the objectives of restraints? - Answer- - protect from injury
- protect others from injury
- maintain treatment
what are some potential complications of restraints? - Answer- - increased risk of falls
- pressure injuries
- contractures
- psychological impacts
- etc
what are the three nursing responsibilities when using restraints? - Answer- -
assessment should be ongoing
- proper documentation
,- should actively involve patient, family, & healthcare team
what should be assessed prior to planning client's elimination needs? - Answer- - health
history (usual patterns, symptoms, etc)
- physical assessment (skin integrity? organ related to voiding's condition?)
what factors can affect urinary elimination? - Answer- - psychological
- sociocultural
- fluid balance
- surgical procedures
- pathological conditions
- medications
what factors can affect bowel elimination? - Answer- - age-related changes
- infectious disease (e.g. norovirus)
- IBS or IBD
- diabetes
- pain
- pelvic floor trauma
- acute illnesses, medications
what age-related changes affect bowel elimination? - Answer- older persons are at a
higher risk of incontinence, constipation due to changes in muscle tone & slowing of
nerve impulses
what is urination? other names? - Answer- the process of emptying the bladder; also
known as micturition, voiding
what is urinary incontinence? why does it occur? - Answer- "an involuntary loss of urine"
due to pelvic lack of muscle strength, control of the bladder and structural damage
what is urinary retention? - Answer- inability to empty the bladder
what are signs of urinary retention? - Answer- - absence of urinary output
- bladder distention
- pain, discomfort
what is defecation? - Answer- elimination of wastes & undigested foods in the form of
feces from the rectum
what is bowel incontinence? - Answer- involuntary passage of feces and gas from the
anus
what are contributing factors to bowel incontinence? - Answer- - diet
- fluid intake
- alcohol
, - nicotine
risks for bowel incontinence? - Answer- - lack of cognitive awareness
- conditions that result in frequent large loose stools
what is flatulence? - Answer- accumulation of gas in the intestines causing the walls to
stretch, resulting in gas passing through the anus
what are signs of constipation? - Answer- - Infrequent bowel movements (less than 3
per week)
- Hard, dry stools that are difficult to pass
- abdominal pain, fullness
what is diarrhea? - Answer- an increase in the number of stools and the passage of
liquid, unformed feces
how can you measure urine output? - Answer- from drainage bag or urine hats
how can you measure urine input? - Answer- measuring what fluids enter the body
during meals or through IV
abnormal urine output? - Answer- - less than 30ml per hour for 2 hours
- <2000-2500 daily
what are normal and abnormal urine colours? - Answer- normal = range from pale straw
to amber
abnormal = red, orange, dark amber
what are normal and abnormal urine clarity levels? - Answer- normal = transparent at
voiding, can become cloudy if left standing
abnormal = cloudy/foamy, thick
what are abnormal urine smells? - Answer- sweet = diabetes or starvation
ammonia = stagnant urine
what are interventions to promote normal micturition? - Answer- - patient education
- promote regular urinary habits (i.e. try not to void too frequently)
- promote complete bladder emptying
- using positions or stimulating the micturition reflex
what are interventions to promote normal bowel elimination? - Answer- - positioning
- ensuring comfort & safety
- address factors that can impact defecation
- ensure adequate fluid intake
- promote physical activity
- medications
