NUR 2356 MULTIDIMENSIONAL CARE 1 EXAM 1
Complications of urinary elimination - ANSWER - UTIs
UTI patient education - ANSWER - wipe front to back
- pee before and after sex
- cleanse beneath foreskin
- provide catheter care regularly (nurses)
A client who has an indwelling catheter reports a need to urinate. Which of the
following actions should the nurse take? - ANSWER A. Check to see whether the
catheter is patent
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis.
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.) - ANSWER 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 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.) - ANSWER 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
A nurse is teaching a client who reports stress urinary incontinence. Which of the
following instructions should the nurse include? (Select all that apply.) - ANSWER A.
Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
E. Use the Credé maneuver
When you see indications of skin breakdown, what is your next action? - ANSWER -
Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints,
wedge pillows)
What does PQRST stand for? - ANSWER Palliative/Provoking
Quality
Region/Radiation
,Severity
Timing
What are some nonverbal signs of pain? - ANSWER - grimacing
- moaning
- flinching
- guarding
- decreased attention span
- restlessness, pacing
What do vital signs look like during acute pain? - ANSWER - BP increased
- Pulse increased
- RR increased
Before nurses give a pain medication, what should they assess? - ANSWER - drug
interactions
- allergies
- vital signs
- side effects
What are common side effects to pain medications? - ANSWER - low BP
- low HR
- sedation
- respiratory depression
- orthostatic hypotension
- urinary retention
- nausea/vomiting
- constipation
After administering pain medication, what is the follow up? - ANSWER - reevaluate
pain level
- if given orally, follow up q 1 hour
- if given IV, follow up q 15 min
- check vital signs!
What are the complications related to pain management? - ANSWER - anxiety
- fear
-depression
- slower healing
- slower recovery
superficial pain usually involving the skin or subcutaneous tissue - ANSWER -
cutaneous pain
pain in internal organs (the stomach or intestines). It can cause referred pain in other
body locations separate from the stimulus - ANSWER - visceral pain
a type of neuropathic pain: sensation of pain without demonstrable physiologic or
pathologic substance; commonly observed after the amputation of a limb - ANSWER
- phantom pain
, Arises from abnormal or damaged pain nerves. It includes phantom limb pain, pain
below the level of a spinal cord injury, and diabetic neuropathy: "pins and needles" -
ANSWER - neuropathic pain
Difference between acute and chronic pain? - ANSWER - -acute pain: lasts less
than 6 mnths, caused by something specific e.g. broken bone -
-chronic pain: lasts more than 6 mnths, caused by an underlying issue, affects ADLs
Chronic pain without identifiable physical or psychological cause - ANSWER -
idiopathic pain
Non-Pharmacological Pain Management strategies - ANSWER - 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
Stages of Therapeutic Communication - ANSWER Pre-interaction
Orientation
Working
Termination
Pre-interaction phase - ANSWER - phase is established even before you meet the
client
- begin establishing communication by gathering information about the client, but the
nurse and client do not have direct communication.
Orientation phase - ANSWER - begins when you meet the client and introduce
yourself and your role in the relationship.
- goal is to establish rapport and trust through the use of verbal and nonverbal
communication.
Working phase - ANSWER - The bulk of therapeutic communication occurs in 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 - 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.
The 5 key characteristics of therapeutic communication - ANSWER -empathy
-respect
-genuineness
Complications of urinary elimination - ANSWER - UTIs
UTI patient education - ANSWER - wipe front to back
- pee before and after sex
- cleanse beneath foreskin
- provide catheter care regularly (nurses)
A client who has an indwelling catheter reports a need to urinate. Which of the
following actions should the nurse take? - ANSWER A. Check to see whether the
catheter is patent
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis.
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.) - ANSWER 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 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.) - ANSWER 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
A nurse is teaching a client who reports stress urinary incontinence. Which of the
following instructions should the nurse include? (Select all that apply.) - ANSWER A.
Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
E. Use the Credé maneuver
When you see indications of skin breakdown, what is your next action? - ANSWER -
Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints,
wedge pillows)
What does PQRST stand for? - ANSWER Palliative/Provoking
Quality
Region/Radiation
,Severity
Timing
What are some nonverbal signs of pain? - ANSWER - grimacing
- moaning
- flinching
- guarding
- decreased attention span
- restlessness, pacing
What do vital signs look like during acute pain? - ANSWER - BP increased
- Pulse increased
- RR increased
Before nurses give a pain medication, what should they assess? - ANSWER - drug
interactions
- allergies
- vital signs
- side effects
What are common side effects to pain medications? - ANSWER - low BP
- low HR
- sedation
- respiratory depression
- orthostatic hypotension
- urinary retention
- nausea/vomiting
- constipation
After administering pain medication, what is the follow up? - ANSWER - reevaluate
pain level
- if given orally, follow up q 1 hour
- if given IV, follow up q 15 min
- check vital signs!
What are the complications related to pain management? - ANSWER - anxiety
- fear
-depression
- slower healing
- slower recovery
superficial pain usually involving the skin or subcutaneous tissue - ANSWER -
cutaneous pain
pain in internal organs (the stomach or intestines). It can cause referred pain in other
body locations separate from the stimulus - ANSWER - visceral pain
a type of neuropathic pain: sensation of pain without demonstrable physiologic or
pathologic substance; commonly observed after the amputation of a limb - ANSWER
- phantom pain
, Arises from abnormal or damaged pain nerves. It includes phantom limb pain, pain
below the level of a spinal cord injury, and diabetic neuropathy: "pins and needles" -
ANSWER - neuropathic pain
Difference between acute and chronic pain? - ANSWER - -acute pain: lasts less
than 6 mnths, caused by something specific e.g. broken bone -
-chronic pain: lasts more than 6 mnths, caused by an underlying issue, affects ADLs
Chronic pain without identifiable physical or psychological cause - ANSWER -
idiopathic pain
Non-Pharmacological Pain Management strategies - ANSWER - 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
Stages of Therapeutic Communication - ANSWER Pre-interaction
Orientation
Working
Termination
Pre-interaction phase - ANSWER - phase is established even before you meet the
client
- begin establishing communication by gathering information about the client, but the
nurse and client do not have direct communication.
Orientation phase - ANSWER - begins when you meet the client and introduce
yourself and your role in the relationship.
- goal is to establish rapport and trust through the use of verbal and nonverbal
communication.
Working phase - ANSWER - The bulk of therapeutic communication occurs in 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 - 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.
The 5 key characteristics of therapeutic communication - ANSWER -empathy
-respect
-genuineness
