Download RNSG 1430 Exam 1 Sensory and Functional Ability exam with precise detailed answers. and more Exams Nursing in PDF only on Docsity!
RNSG | 1430 |Exam | 1 |Sensory |and |Functional |
Ability |exam |with |precise |detailed |answers
Peripheral |Neuropathy |- |ANSWER-(nerve |damage |in |extremities) |hands |and |feet |biggest |concern. | Check |for |injuries/ |wounds. decreased |tactile |sense Risk |factors |for |peripheral |neuropathy |- |ANSWER--diabetes -impaired |perfusion -smoking Risks |of |peripheral |neuropathy |- |ANSWER--thermal |burns -falls -wounds -infections -sores |in |areas |they |cant |feel Any |sensory |condition |that |reduces |vision |- |ANSWER--communicate |with |adaptive |items |ie; |brail -safety |in |familiar |settings -ambulation |with |blind |cane -never |grab |a |blind |or |low |vision |patient. |( |blind |folded |activity |in |class) Safety/ |helpful |precautions |for |reduced |vision |- |ANSWER--orient |to |surroundings -increase |amount |of |light |w/o |glare -bright |colors |are |more |distinguishable | -remove |hazards: |throw |rugs, |electric |cords, |coffee |table, |etc. -make |a |clear |path |to |the |bathroom
Prevention |of |reduced |vision |- |ANSWER-snellen |eye |chart- |used |to |check |distance |vision Therapeutic |communication |for |reduced |vision |- |ANSWER-" |tell |me |more", |"how |do |you |feel |when..." Cataracts |- |ANSWER-lens |of |the |eye |becomes |cloudy. | can |be |in |one |or |both |eyes No |pain |or |redness |is |associated |with |age-related |cataracts Is |Cataracts |acute |or |chronic? |- |ANSWER-Acute! Cataract |surgery |- |ANSWER-cataract |surgery |is |curative. |the |lens |in |the |eye |is |removed |and |replaced | with |an |artificial |lens. CVA |nursing |interventions |- |ANSWER-1. |Meds |as |ordered |
- |antihypertensives
- |antilipidemic |
- |anticoagulant |
- |antiplatelet |
- |Swallowing |precautions |
- |Contacting |community |resources-patient/family |education
- |Physical/occupational/speech |therapies CVA |Possible |Nursing |Diagnosis |- |ANSWER-- |Ineffective |cerebral |tissue |perfusion |
- |impaired |physical |mobility |
- |disturbed |sensory |perception |
- |self |care |deficit |
- |imbalanced |nutrition, |less |than |body |requirements |
- |impaired |skin |integrity |
7 |Stages |of |Alzheimer's |Disease |(fourth) |- |ANSWER-Mild |or |early |stage |AD
- |symptoms |are |obvious
- |considerably |accurate |Diagnosis |
- |functionally |may |continue |to |be |able |to |live |independently 7 |Stages |of |Alzheimer's |Disease |(fifth) |- |ANSWER-Moderate |AD |
- |lose |ability |to |live |independently 7 |Stages |of |Alzheimer's |Disease |(sixth) |- |ANSWER-Moderately |severe |AD
- |unable |to |perform |BADLs
- |need |help |dressing 7 |Stages |of |Alzheimer's |Disease |(seventh) |- |ANSWER-Completely |lose |ability |to |respond |to | surroundings |and |function |without |continuous |assistance
- |frequently |die |from |aspiration |or |infected |pressure |ulcer Preventing |Injury |AD |- |ANSWER-- |keep |clutter |clear
- |install |grab |bars |
- |remove |throw |rugs
- |remove |electrical |cords
- |make |sure |shoes |fit |and |support Interventions |in |AD |- |ANSWER-- |provide |cognitive |restructuring |and |memory |training |
- |structure |the |environment |to |increase |patients |ability |to |function |
- |provide |CONSISTENCY, |orientation, |and |validation |therapy |
- |promote |bowel |and |bladder |continence |
- |promote |independence |in |activities |o |daily |living |
- |provide |communication |with |clear, |short |sentences
More |interventions |in |AD |- |ANSWER-Assist |with |facial |recognition |as |the |disease |progresses |to | prosopagnosia |(an |inability |to |recognize |oneself |and |other |familiar |faces) Drug |for |AD |- |ANSWER-Aricept |— |donepezil |
- |is |used |to |treat |mild |to |moderate |dementia |caused |by |Alzheimer's |disease Side |effects |are |headache, |diarrhea, |nausea Nursing |diagnosis |for |AD |- |ANSWER-Uirinary |and |bowel |elimination |related |to |neurological |function | loss/ |muscle |tone |
- |disturbed |sleep |pattern |related |to |sensory |changes |
- |Impaired |physical |mobility |related |to |neuromuscular |damage |
- |self |care |deficit Down |syndrome |- |ANSWER-Lab- |multiple |marker |screen- | Screens |fetus |for |DS
- |trisomy | 18 |or | 21
- |neutral |tube |deficits |
- |other |chromosomal |abnormalities | DS |occurs |when |the |individuals |cells |contain |a |third |or |partial |copy |of |the |21st |chromosome DS |possible |nursing |diagnosis |- |ANSWER-- |imbalanced |nutrition- |less |than |body |requirements |related | to |difficulty |feeding |due |to |tongue |far |and |high |palate |
- |risk |for |injury |related |to |reduced |hearing
- |ineffective |family |coping |related |to |financial |factors |required |in |maintenance |
- |lack |of |social |interaction |related |to |physical |and |mental |limitations |that |they |have |
- |knowledge |deficit |(parents) |related |to |DS |childcare DS |nursing |care |- |ANSWER-Educate |[arents |to |train |the |child |to |be |as |independent |as |possible |
- |focus |on |developmental |skills
- |educate |parents |to |encourage |self |care |skills |in |the |child |
- |brain |cells |begin |to |die |within |3-7 |minutes |without | 02 |— |irreversible CVA |uncontrollable |risk |factors |- |ANSWER-- |HTN |(hypertension)
- |Afib |
- |increased |lipids
- |smoking
- |obesity
- |Age |(usually |increasing |age)
- |Sex
- |Race Genetics Parkinson's |Disease |- |ANSWER-Slowly |progressing |neurological |movement |disorder |that |eventually | leads |to |disability Parkinson's |Possible |nursing |diagnosis |- |ANSWER-- |impaired |physical |mobility, |verbal |communication |
- |risk |for |injury |/ |actual |imbalance |nutrition |
- |self |care |deficits |
- |constipation |
- |ineffective |coping/compromised |family |coping Parkinson's |Drug |- |ANSWER-Carbidopa/ |levodopa |
- |carbidopa |decreases |levodopas |conversion |in |the |periphery |
- |side |effects |GI |hemorrhage, |anxiety, |dizziness, |drowsiness, |blurred |vision Major |goal |of |Parkinson's |disease |- |ANSWER-Improved |functional |ability
- |BADLs |
- |maintains |independence |
- |achieve |adequate |bowel |elimination
- |attain |and |maintain |acceptable |nutritional |status |
- |achieve |effective |communication
- |develop |positive |individual |and |family |coping |skills Parkinson's |Disease |- |ANSWER-Associated |with |decreased |levels |of |daopmaine |due |to |destruction |of | cells |in |the |substantia |nigra |in |the |basal |ganglia; |this |effects |the |neurotransmitter |of |impulses Cataract |treatment |- |ANSWER-Ambulatory |surgery |
- |pre-op |teaching |
- |local |anesthesia, |sedative |- |home | 1 |hour |after |surgery |
- |multiple |eye |drops |— |TID |x |2-4 |weeks |
- |Eye |assessment Cataracts |post-op |care |- |ANSWER-- |eye |is |unpatched |(usually)
- |eye |shield |
- |discharge |usually |occurs |within |one |hour |with |dark |glasses
- |instill |antibiotic-steroid |eye |drops
- |mild |itching |is |normal |
- |pain |indicates |a |complication |
- |reduce |IOP |(usually |ordered)
- |prevent |infection
- |assess |for |bleeding Cataract |risk |factors |- |ANSWER-Aging Heredity | Eye |trauma Diabetes |mellitus | Chronic |steroid |use
- |lifting |objects |over |10lb
- |coughing, |sneezing, |blowing |nose
- |constipation, |straining
- |vomiting
- |sex
- |tight |collars Glaucoma |risk |factors |- |ANSWER-Aging Heredity African |American |race Diabetes |mellitus | Infection Tumors Cochlear |implant |- |ANSWER-- |used |with |sensorineural |hearing |loss
- |electrodes |near |inner |ear
- |computer |device |external |ear |
- |50% |hearing |improvement Primary |open-angle |glaucoma |clinical |manifestations |- |ANSWER-- |generally |no |symptoms
- |elevated |IOP |(>21 |mmHg)
- |loss |of |peripheral |vision |
- |usually |affects |both |eyes
- |untreated |= |blindness Glaucoma |- |ANSWER-- |decrease |fluid |rain |age |or |increase |fluid |production |
- |group |of |ocular |diseases |resulting |in |increased |IOP | Disturbance |of |the |optic |nerve |
- |primarily |open-angle |glaucoma
- |angle |closure |glaucoma Vision |with |glaucoma |- |ANSWER-Dark |halo |around |everything Diagnostic |tests |- |ANSWER-- |tonometry | —- |measures |IOP |(normally |10-21mmHg)
- |gonioscopy —- |determines |the |drainage |angle |of |the |anterior |chambers |of |the |eye
- |ophthalmoscopy |
- |visual |field |perimetry |
- |optic |disc |photographs |
- |optic |nerve |imaging |- |used |at |regular |intervals |to |assess |for |loss |of |optic |nerve |fibers Glaucoma |drug |therapy |- |ANSWER-- |reduce |production |or |increase |absorption |of |acqueous |humor |
- |prostaglandin |analogs |
- |alpha-adrenergic |antagonists |
- |beta-blockers |
- |cholinergic |agaonists |(miotics |- |constrict |the |pupil)
- |carbonic |anhydrase |inhibitors Patient |teaching |- |administration |of |eye |drops |- |ANSWER-Dont |skip |doses |
- |punctual |occlusion |
- |if |more |than |one |medication, |wait |5-15 |minutes |between |doses GLaucoma |surgery |- |ANSWER-- |laser |or |conventional |
- |ambulatory |surgery Post |op |care | —-IOP |checked |by |surgeon |1-2 |hrs | —-eye |patch |or |shield |
Statins | Pegaptanib |(macugen) |eye |injections |and |laser |surgery Eye |injury |/ |trauma |- |ANSWER-Eye |trauma |- |leading |cause |of |blindness |in |children |and |young |adult Treatment |of |eye |injuries |- |ANSWER-Splash |injuries- |irrigate Foreign |bodies- |cover |and |seek |treatment |q Signs |and |symptoms |of |reduced |vision |- |ANSWER-- |frequent |headaches
- |Reports |of |blurred/double |vision |
- |closes |one |eye |to |read |
- |trips |over |or |bumps |into |furniture |
- |poor |depth |perception |
- |inability |to |discriminate |between |similar |colors |and |shapes | NO |PERRLA Interventions |to |maintain |safety |with |reduced |vision |- |ANSWER-- |increase |amount |of |light |without | glare |
- |utilize |bright |colors
- |remove |hazards —- |throw |rugs | —- |electric |cords —-coffee |tables | —- |clear |path |to |bathroom ORIENT |to |surroundings Causes |of |reduced |vision |- |ANSWER-- |refractory |errors
- |cataracts |
- |glaucoma |
- |diabetic |retinopathy
- |macular |degeneration
- |eye |infection
- |eye |injury |
- |tumors Communicating |with |the |hearing |impaired |- |ANSWER-They |can |see |your |lips |during |conversation
- |use |good |lighting |
- |get |patients |attention |before |talking |
- |move |closer |to |hearing |ear
- |speak |clearly |and |slowly
- |dont |shout |
- |minimize |distracting |noises Community |resources |for |hearing |loss |- |ANSWER-ADARA- |American |deafness |and |rehabs=imitation | association | RID |- |registry |of |interpreters |for |the |Deaf Soft |TTY |- |sales@softty.com NAD |- |national |association |for |the |deaf Causes |of |neural |hearing |loss |- |ANSWER-Ménière's |disease Other |diseases: |atherosclerosis, |HTN, |fever, |DM
- |ear |surgery, |acoustic |neuroma Causes |of |sensorineural |Hearing |loss |- |ANSWER-Loud |noises Aging Ototoxic |drugs Antibiotics |(gentamicin, |amikacin, |vancomycin) Diuretics |(furosemide)
-light |scatter |(halos |around |headlights |especially |at |night) -glare Cataracts |risk |factors |- |ANSWER--aging -heredity -eye |trauma |(traumatic |cataract) -diabetes |mellitus | -chronic |steroid |use -sun |exposure -smoking |cigarettes Catarac |Pre |OP |teaching |- |ANSWER--Local |anesthesia, |sedative -Home | 1 |hour |after |surgery -Multiple |eye |drops |TID |x |2-4 |weeks -Eye |assessment Post |Op |care |for |cataract |surgery |- |ANSWER--usually |unpatched -eye |shield |is |given |to |wear |after |surgery |for |a |certain |amount |of |time |and |then |typically |at |night | while |sleeping |avoid |rubbing |the |eye -discharge |usually |occurs |within | 1 |hour |with |dark |glasses -mild |itching |is |normal- |the |eye |is |healing! -avoid |bending, |lifting, |straining, |sexual |activity, |sneezing, |blowing |nose, |etc. these |activities |can |increase |the |intraocular |pressure -follow |up |appointment |usually |in | 48 |hours |after |surgery What |would |pain |indicate |after |Cataract |surgery? |- |ANSWER-Complication!! Glaucoma |- |ANSWER-elevated |intraocular |pressure |(IOP)
What |are |two |main |types |of |glaucoma? |- |ANSWER--primary |open |angle |glaucoma -angle |closure |glaucoma Is |Glaucoma |acute |or |chronic? |- |ANSWER-Chronic! Causes |of |Glaucoma |- |ANSWER--can |be |caused |from |increased |fluid |production -decreased |fluid |drainage -optic |nerve |disturbed -primary |open |angle |glaucoma |is |the |most |common Risk |factors |for |Glaucoma |- |ANSWER--age -heredity -more |common |in |african |americans -diabetes |mellitus | -glaucoma |can |be |secondary |to |tumors |(the |pressure |from |the |tumor |increases |the |pressure |in |the | eye) -can |be |a |side |effect |of |cataract |extraction Manifestation |of |open |angled |glaucoma |- |ANSWER--generally |no |symptoms |to |start -elevated |IOP |>21 |mm |Hg -loss |of |peripheral |vision |over |time -decreased |accommodation -usually |affects |both |eyes -untreated=blindness How |long |should |a |glaucoma |patient |take |their |eye |drops? |- |ANSWER-Forever!!! |the |drops |slow |the | progression |of |the |disease Diagnostic |tests |for |glaucoma |- |ANSWER--Tonometry- |Measures |IOP |(normal |10-21 |mm |Hg)
-nausea |and |vomiting What |is |considered |legal |blindness? |- |ANSWER-20/200 |with |corrective |lenses Macular |Degeneration |- |ANSWER--degeneration |of |the |macula |reducing |central |vision -rod |and |cone |photoreceptors |die -patient |reports |mild |blurring, |distortion, |or |a |blind |spot Macular |Degeneration |risk |factors |- |ANSWER--aging -hypertension -smoking -family |history -sun |exposure -light |colored |eyes |have |higher |risk |of |developing |macular |degeneration Two |types |of |macular |degeneration |- |ANSWER--dry -wet |(worse) Dry |Macular |Degeneration |- |ANSWER-atrophic |age |related Wet |Macular |Degeneration |- |ANSWER-exudative Treatments |for |Macular |Degeneration |- |ANSWER--quit |smoking -control |of |HTN -Vitamins |(C, |E, |Beta |Catotene, |Zinc, |etc.) -Beta |Carotene- |carrots |for |good |eyes -Zinc- |in |sunscreen -statins -pegaptanib |(macugen) |eye |injections
-laser |surgery Eye |trauma |- |ANSWER-the |leading |cause |of |blindness |in |children |and |young |adults Treatment |of |eye |injuries |- |ANSWER-splash |injuries- |irrigate foreign |bodies- |cover |and |seek |treatment Hearing |loss |- |ANSWER-one |of |the |most |common |physical |handicaps |in |north |america Two |types |of |hearing |loss |- |ANSWER--conductive -sensorineural Causes |of |Conductive |hearing |loss |- |ANSWER--inflammatory |process -tympanic |membrane |perforation -obstruction |of |the |external |or |middle |ear |by |cerumen |or |foreign |objects -otosclerosis Causes |of |Sensorineural |hearing |loss |- |ANSWER--loud |noises -aging -ototoxic |drugs |(antibiotics, |diuretics, |NSAIDS, |chemo) -Menier's |disease -atherosclerosis -HTN -fever -diabetes |mellitus -acoustic |neuroma Treatment |of |hearing |loss |- |ANSWER--early |detection -drug |therapy
