Card Set Information
Foundation Test Questions
Nursing Interventions for Inflammation & infections of
1.A nurse would measure a
clients intake and output.
1a.Rationale: helps evaluate client's fluid and electrolyte balance
2. A nurse can provide
2a. Rationale: Because this can be humiliating to the client and by providing psychological support it will help the client gain self confidence.
3. A nurse can provide
Suprapubic tapping/thigh stroking
: This will stimulate a reflex and promote voiding
Nursing Interventions for Nausea and Vomiting
1. Remove triggers for N&V from environment (ie Odours)
: removing the trigger will prevent / decrease the N&V.
2. A nurse can provide frequent mouth care
: Providing frequent mouth care gives client sense of cleanliness and promotes health care.
3. A nurse can ensure that medicine for the pain is provided.
: As an anti-inflammatory and mild analgesic effect in reducing stiffness and will improve mobility for patient.
Nursing intervention for Constipation or Diarrhea
1. A nurse should ensure the client has access to the call bell.
: This way the client will feel confident that a nurse will be there right away to help.
2. A nurse can remove the stool promptly
: Patient will be in a clean environment
3. A nurse should use contact precautions if an infection is suspected.
: This will help with infection control for the client/nurse and hospital
Describe two types of bowel sounds?
1. Normal sounds (sounds heard every 5-20 seconds)
2. Hypoactive sounds (hearing 1-2 sounds every 2min)
Nursing diagnosis for N&V for client who is getting chemo
Imbalanced nutrition (less than body requirement)
nausea and vomiting
for N&V with chemo
Client will experience fewer episodes of N&V before, during and after chemotherapy
Nursing diagnosis for Diarrhea
Deficient Fluid Volume related to excessive fluid loss through the stool or vomit
Nursing GOAL for Diarrhea
Client a regular pattern of bowel elimination within 2days.
nursing diagnosis for dehydration:
Deficient fluid volume related to fluid lost through vomiting and inadequate fluid intake
Nursing goal for dehydration:
Client will report absence of vomiting within one day
What is the rationale for giving a client antiemeis?
to prevent nausea and vomiting
What are the 6 types of incontinence?
Functional - urinary system intact. BR to far
Urge - involuntary elimination
Mixed - more tan one type of incontinence
Stress - weak muscle permits leakage
Overflow - abnormal bladder emptying
Reflex - no sensory awareness to void
Name manifestation of DIARRHEA
1. Abdominal cramps
name manifestation for constipation:
2. Small dry hard stool
3. Sensation of incomplete emptying
What is tPA? And what does it stand for?
Tissue Plasminogen Activator
This dissolves blood clots
tPA is a drug that can stop a stroke caused by a blood clot by breaking up the clot.
can only be given to patients who are having a stroke caused by a blood clot (ischemic stroke).
Nursing intervention for client w/Stroke that has dysphasia (difficulty swallowing)
A nurse could provide or do the following:
1. Allow client ample time to eat
2. Place food on unaffected side
3. Up-right position for meals
4. No straw
What are the 7 A's?
1. Amnesia - loss of memory
2. Aphasia - loss of language
3. Agnosia - Loss of recognition
4. Apraxia - loss of purposeful movement
5. Anosognosia - no knowledge of their disease
6. Apathy - lack of interest
7. Altered Perception - loss of visual acuity/judgement
loss of memory
loss of language
Loss of recognition
Loss of purposeful movement
no knowledge of their disease
lack of interest
Altered Perception is?
loss of visual acuity/judgement
What is multiple sclerosis
condition that affects CNS (Brain & spinal cord)
myelin sheath becomes inflamed and damaged once the injury occurs, electrical signals in the brain are slowed down.
autoimmune disease (immune system starts reacting against own tissues)