KU SON Health and Illness Exam 2 Questions and Answers Fully Solved
How would you establish an individualized plan of care to meet nutritional needs of a patient? - Answers
Take into account risk factors, potential nutrient deficiencies, genetics, lifestyle, and allergies
Dietary guidelines for health promotion - Answers DRI (dietary reference intake) values on labels >
reinforce dietary guidelines, Macronutrients: Ca, Fe, Vit A, Vit C, and ADA guidelines (MyPlate)
Clinical signs of a patient's nutritional status - Answers physical measurements (BMI, waist
circumference), biochemical, and dietary data
**a plan of action for nutritional intervention is based on the results of the dietary assessment and the
patient's clinical examination
Nutritional assessment - Answers Assess food intake and output, physical status, food preferences,
weight changes, and cultural practices in eating
- Nutrition screening, Ideal body weight, BMI, and physical exam
Nursing interventions that promote optimal nutrition - Answers Teach patients about optimal nutrition
(on a budget, on a diet, while avoiding allergens, etc.)
Pregnancy Nutritional Needs - Answers Need nutrition to provide for the development of the fetus,
mothers need to eat nutrients that aide in the growth and development of the fetus
- Folic Acid
Infancy Nutritional Needs - Answers most growth and development occurs in the first year, without
adequate nutrition developmental milestones may not be reached
- breastmilk and formula for the first 6 months, introduce solid foods after 6 months
Elderly Nutritional Needs - Answers slower metabolism, ingestion, and, absorption
- ensure adequate fiber and fluid intake
- low sodium
Risk factors for nutritional deficiencies and nursing interventions for at risk populations - Answers Age or
life stage- teach about optimal nutrition for age or life stage
Ethnicity/race- teach about optimal nutrition for race
,Poor/underserved- educate on healthy choices on a budget/ food banks that supply healthy food for
free
Genetics
Lifestyle and patterns of eating- educate on healthy choices
Personal food choices- educate on healthy choices
Underlying medical issues- teach about optimal nutrition for medical issues
Enteral nutrition - Answers Alternate form of feeding that involves passing a tube into the
gastrointestinal tract to allow instillation of the appropriate formula
Parenteral nutrition - Answers Giving nutrients through an IV inserted into a vein
Failure to thrive - Answers A condition in which infants become malnourished and fail to grow or gain
weight for no obvious medical reason
- Underlying metabolic factors, incorrect formula, not latching, frustration with breastfeeding
Pancreatitis - Answers self digestion of the pancreas by its own enzymes, can also be caused by bacterial
or viral infections
- Mortality rate 2-10% Because of shock, anoxia, hypotension, fluid or electrolyte imbalances, Severe
abdominal pain, Hypotension, hypovolemia, shock
- Morphine, fentanyl, and hydromorphone- assess for effectiveness and alter therapy if pain is not
controlled or increases
Gastrostomy - Answers used for direct access to stomach with tube feedings
Tissue Integrity - Answers structural intactness and physiologically functioning integumentary tissues
and mucous membranes
How do you assess tissue integrity? - Answers Adequate perfusion, Environmental protective barrier,
Intact integumentary system, Sensation, Thermoregulation, Absorption, Secretion of mucous and tears,
Excretion of wastes
Skin Integrity - Answers specifically focused on damage to the epidermal and dermal layers of epithelial
tissue, but deep damage to skin integrity is associated with disruption of underlying tissues
Importance of skin as an organ - Answers Skin > your body's greatest protector!
- The largest organ of the body, First line of defense from infection, Temperature regulation, Prevents
water loss, Sensation, Synthesizes vitamin D
, Risk factors that cause alterations in tissue integrity - Answers Poor nutrition, poor peripheral perfusion,
Obesity, Diabetes, Fluid deficit or excess, Impaired physical mobility, Chemical irritants, Radiation,
Extreme temperatures, Medical procedures
- Populations at Risk: Infants and children, Elderly adults, ICU patients
Stage 1 Pressure Ulcer - Answers Intact skin with non-blanchable redness of a localized area usually over
a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the
surrounding area.
Stage 2 Pressure Ulcer - Answers Partial thickness loss of dermis presenting as a shallow open ulcer with
a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled
blister.
Stage 3 Pressure Ulcer - Answers Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed. Slough may be present but it does not obscure the depth of tissue
loss. May include undermining and tunneling.
Stage 4 Pressure Ulcer - Answers Full thickness tissue loss with exposed bone, tendon or muscle. Slough
or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Suspected Deep Tissue Wound - Answers A purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
- The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared
to adjacent tissue.
Unstageable Pressure Ulcer - Answers Full thickness tissue loss in which the base of the ulcer is covered
by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Wounds - Answers Caused by direct or indirect tissue injury
Wound Assessment - Answers Assess location, size, shape, and color, odor, and consistency of any
drainage or exudate
Redness of the surrounding tissue, foul odor, or purulent drainage may indicate wound infection.
- A surgical wound may be left open to the air or covered with a dressing to protect the wound site and
absorb drainage. Covered wounds should be carefully assessed when the wound is exposed during
dressing changes.
Wound Healing - Answers wounds heal from the inside out so you have to protect from infection
How would you establish an individualized plan of care to meet nutritional needs of a patient? - Answers
Take into account risk factors, potential nutrient deficiencies, genetics, lifestyle, and allergies
Dietary guidelines for health promotion - Answers DRI (dietary reference intake) values on labels >
reinforce dietary guidelines, Macronutrients: Ca, Fe, Vit A, Vit C, and ADA guidelines (MyPlate)
Clinical signs of a patient's nutritional status - Answers physical measurements (BMI, waist
circumference), biochemical, and dietary data
**a plan of action for nutritional intervention is based on the results of the dietary assessment and the
patient's clinical examination
Nutritional assessment - Answers Assess food intake and output, physical status, food preferences,
weight changes, and cultural practices in eating
- Nutrition screening, Ideal body weight, BMI, and physical exam
Nursing interventions that promote optimal nutrition - Answers Teach patients about optimal nutrition
(on a budget, on a diet, while avoiding allergens, etc.)
Pregnancy Nutritional Needs - Answers Need nutrition to provide for the development of the fetus,
mothers need to eat nutrients that aide in the growth and development of the fetus
- Folic Acid
Infancy Nutritional Needs - Answers most growth and development occurs in the first year, without
adequate nutrition developmental milestones may not be reached
- breastmilk and formula for the first 6 months, introduce solid foods after 6 months
Elderly Nutritional Needs - Answers slower metabolism, ingestion, and, absorption
- ensure adequate fiber and fluid intake
- low sodium
Risk factors for nutritional deficiencies and nursing interventions for at risk populations - Answers Age or
life stage- teach about optimal nutrition for age or life stage
Ethnicity/race- teach about optimal nutrition for race
,Poor/underserved- educate on healthy choices on a budget/ food banks that supply healthy food for
free
Genetics
Lifestyle and patterns of eating- educate on healthy choices
Personal food choices- educate on healthy choices
Underlying medical issues- teach about optimal nutrition for medical issues
Enteral nutrition - Answers Alternate form of feeding that involves passing a tube into the
gastrointestinal tract to allow instillation of the appropriate formula
Parenteral nutrition - Answers Giving nutrients through an IV inserted into a vein
Failure to thrive - Answers A condition in which infants become malnourished and fail to grow or gain
weight for no obvious medical reason
- Underlying metabolic factors, incorrect formula, not latching, frustration with breastfeeding
Pancreatitis - Answers self digestion of the pancreas by its own enzymes, can also be caused by bacterial
or viral infections
- Mortality rate 2-10% Because of shock, anoxia, hypotension, fluid or electrolyte imbalances, Severe
abdominal pain, Hypotension, hypovolemia, shock
- Morphine, fentanyl, and hydromorphone- assess for effectiveness and alter therapy if pain is not
controlled or increases
Gastrostomy - Answers used for direct access to stomach with tube feedings
Tissue Integrity - Answers structural intactness and physiologically functioning integumentary tissues
and mucous membranes
How do you assess tissue integrity? - Answers Adequate perfusion, Environmental protective barrier,
Intact integumentary system, Sensation, Thermoregulation, Absorption, Secretion of mucous and tears,
Excretion of wastes
Skin Integrity - Answers specifically focused on damage to the epidermal and dermal layers of epithelial
tissue, but deep damage to skin integrity is associated with disruption of underlying tissues
Importance of skin as an organ - Answers Skin > your body's greatest protector!
- The largest organ of the body, First line of defense from infection, Temperature regulation, Prevents
water loss, Sensation, Synthesizes vitamin D
, Risk factors that cause alterations in tissue integrity - Answers Poor nutrition, poor peripheral perfusion,
Obesity, Diabetes, Fluid deficit or excess, Impaired physical mobility, Chemical irritants, Radiation,
Extreme temperatures, Medical procedures
- Populations at Risk: Infants and children, Elderly adults, ICU patients
Stage 1 Pressure Ulcer - Answers Intact skin with non-blanchable redness of a localized area usually over
a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the
surrounding area.
Stage 2 Pressure Ulcer - Answers Partial thickness loss of dermis presenting as a shallow open ulcer with
a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled
blister.
Stage 3 Pressure Ulcer - Answers Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed. Slough may be present but it does not obscure the depth of tissue
loss. May include undermining and tunneling.
Stage 4 Pressure Ulcer - Answers Full thickness tissue loss with exposed bone, tendon or muscle. Slough
or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Suspected Deep Tissue Wound - Answers A purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
- The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared
to adjacent tissue.
Unstageable Pressure Ulcer - Answers Full thickness tissue loss in which the base of the ulcer is covered
by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Wounds - Answers Caused by direct or indirect tissue injury
Wound Assessment - Answers Assess location, size, shape, and color, odor, and consistency of any
drainage or exudate
Redness of the surrounding tissue, foul odor, or purulent drainage may indicate wound infection.
- A surgical wound may be left open to the air or covered with a dressing to protect the wound site and
absorb drainage. Covered wounds should be carefully assessed when the wound is exposed during
dressing changes.
Wound Healing - Answers wounds heal from the inside out so you have to protect from infection
