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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)
Foundation Test Questions