regulation 2

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(Diet Therapies) What is mechanical soft diet?: used with clients having difficulty chewing or unable to throoughly chew food. It makes the food softer than the "soft diet".
The evaluation of pain......: -Should be ongoing
-focuses on the client's subjective reports
Clients taking pain medications will become addicted to the drug?: False
What type of nursing assessment is done for Sleep and rest disorder?: -Nature of problem
-quality of the problem
-Environmental factors
-Associated factors (food, activity, anxiety level, pain, routines)
-Alleviating factors
-Effect of the problem.
What type of a diet would someone who has renal failure be on?: Sodium-restricted diet
and low potassium diet.
What nursing diagnosis is used for Sleep/Rest problems?: Sleep Pattern Disturbance
What is the physiology of sleep?: It is controlled by the centers in the brain.

Influenced by routines and environmental factors
(Common Sleep Disorders) What are parasomnias?: Activation of physiological systems-sleepwalking, bed wetting, teeth grinding.
What is bowel elimination?: Eliminates solid wastes
(80% of what you eat today is excreted in 5 days)
What are the implementations for Pain?: pharmacologic: (medications) Start with non-narcotic and then go up
Nonpharmocologic:
-Touch
-Distraction
-Relaxation tech.
-Cutaneous stimulation (cryotherapy(heat/cold), TENS
-Exercise
What is regression?: Return to a less mature behavior to solve a conflict or problem.
What diet would somebody who has obesity be on?: low fat diet
After REM sleep the cycle starts over at what point?: NREM 2
Name the four stages of Non-rapid eye movement sleep.: Stage 1-light quality, lasts 10 min.
Stage 2-50% of normal adult sleep.
Stage 3-medium-depth sleep
Stage 4-Sleepwalking, night terrors (kids).

* The growth hormone peaks between levels 3 and 4.
Outcomes of stress are?: Adaptation:Ongoing process by which individuals adjust to stressors to achieve homeostasis (equilibrium between physiological,psychological, sociocultural, intellectual, and spiritual needs.
Maladaptation: When coping mechanisms are ineffective.
Eustress: Results in positive outcomes.
Distress: Ineffective response.
What are the nursing interventions for elimination?: -Ensure adequate fluid intake (1.5-2 L/QD)
-Avoid bladder irritants (caffeine, juice)
-Encourage regular elimination patterns
-Encourage exercise(constipation)
-Monitor skin itegrity
-Increase fiber in the diet (constipation)
-Assess for bladder distension and catheterization
-Positioning: sitting vs. standing
-teaching proper hygeine (wiping from front to back)
-
Most complaints of pain are purely psychological?: False
Clients minimize pain behaviors because it isn't macho to show pain?: False
What are the nursing diagnosis for pain?: Acute pain-less than 6 months
Can be cured or eleviated.

chronic pain-greater than 6 months. No anticipated end for chronic pain.
Potential tissue damage is always associated with pain?: True
What is stress?: It is a univeral experience.
It can cause a positive change or discomfort and pain.

*stress management necessary for the wellness of the nurse as well as the client.
(Diet Therapies) What is a high-fiber diet?: Raw Veg & fruits, seeds, plan fiber, whole grains
(patient with constipation, or diarrhea)
Defense Mechanisms to stress are..........: Denial
Rationalization
Repression
Displacement
Reaction formation
Supression
Projection
Regression
Undoing
(Common Sleep Disorders) Insomnia is defined as?: Chronic inability to sleep.
What are the common alterations in bowel elimination?: -constipation(infrequent and difficult passage of stool)
-fecal impaction (stool hard)
-diarrhea (liquid stool)
-fecal incontinence (Involuntary loss of stool)
-flatulence(gas)
-hemorrhoids(Perianal variacosity of the hemorrhoidal veins)
-ostomies
How long does the sleep cycle last?: 70-90 minutes.
What are the nursing implications for moderate anxiety?: Help the client to determine a cause-and-effect relationship between stressor and anxiety.
What is displacement?: Transferring the emotional feeling from one object to another.
(Diet Therapies) What is a sodium and potassium restriction diet?: It is used for hypertension, caridac and renal patients.
Clients with severe tissue damage experience severe pain; those with less damage have less pain?: False
regulation sensory/perception/cognition feeling These are all pertain to what?: Stess
(Diet Therapies) What is a fat controlled diet?: reduced total fat.
(cardiac patients or patient who want to loose weight)
Stress related disorders..........: either occur or increase during periods of stress.
What are the safety considerations for nutritional support?: -assess the client for signs of gastric retention.
-Monitor feeding tube placement.
-Assess client for pulmonary aspiration.(color & consistency of the sputum.
-keep the client in a high Flowler's position.
-dlute feedings to half strength and slow the feeding time to prevent diarrhea.
What are some factors affecting sleep and rest?: Degree of comfort
Anxiety
Environment
Lifestyle
Diet
Drugs
Culture
Age
What is the reaction formation?: Develops conscious attitudes opposite of real unconscious attitudes.
Nursing Interventions for Nutrition are?: -Weigh patient daily (same time each day)
-Record I & O
-Promote patient participation in dietary planning. (are they able to put the food in their mouths?)
-Encourage the client to verbalize feeling concerning food (encourage meal planning)
-provide nutritional support as needed (some hospitals requre an order for a dietician)
-Discuss realistic goals for weight loss.
-Discharge planning (can they go buy the food themselves?
Or can food be delivered? call social services for "Meals on wheels"
What are the nursing diagnosis for elimination problems?: -altered urinary elmination
-bowel incontinence
-constipation
-diarrhea
-incontinence (functional, stress, etc.)
-urinary retention
-self-esteem disturbance
-knowledge deficit
-risk for infection
-skin integrity
-self care deficit: toileting
lab value for BUN?: 10-20mg/dl
What is the definition of stress?: Stress is the reaction of the body to any stimulus. The wear and tear on the body.
What is a stressor?: Any situation, event or agent that threatens a person's security.
a. Evokes need to adapt
What is the pattern of the sleep cycle?: NREM 1
NREM 2
NREM 3
NREM 4
NREM 3
NREM 2
REM
What is projection?: Denies the problem as well as blames others.
Can a person with hemorrhoids still have a rectal temperature taken?: Yes. Incombant position
How do you determine which route of nutrition support to use?: -The patients GI function
-Expected duration of therapy
-Aspiration risk
-Potential for or actual development of organ dysfunction.
Common alterations in Urinary elimination are:: -urinary retention
-urinary tact infection (UTI)
-Urinary incontinence (inability to control urine)
-Enuresis(uncontrollable release of urine)
-Ureterostomies
-nocturia (urination during sleep)
-polyuria(frequent urination)
-oliguria (low urination)
-anuria (no urine)
-hematuria (blood in urine)
-proteinuria (protein in urine)
-pyuria (puss in urine)
-bacteriuia (bacteria in urine)
Nursing Diagnosis used for Nutrition are?: -Altered nutrition: less than body requirements.

-Altered nutrition: more than body requirements.

-Other diagnosis: skin integrity impaired R/T inadequate intake of proteins.
What are the nursing implications for severe anxiety?: Encourage verbalization, Engage in motor activity,
Give specific directions.
Clients minimize pain behaviors because they want to be a good patient?: True
(Common Sleep Disorders) What is sleep deprivation?: Prolonged inadequate quality/quantity of sleep
What are the two routs of nutritional support?: Enteral nutrition
Parental nutrition
What does a nurse Assess when she is doing a pain Assessment?: -Intensity(1-20 scale, Oucher, Wong-Baker)
-Location(What to treat, help DX, help with testing and meds.)
-quality(sharp, dull, continuous)
-Associated manifistations
-Aggravating factors (what makes it worse?)
-Alleviating factors (What makes it better?)
-Scales
If pain is ignored, it will go away?: False
(Common Sleep Disorders) What is sleep apnea?: pauses in breathing of 30-60 seconds with loud snoring episodes.
When clients are exhausted, they have increased pain?: True
(Impact of Illness and Treatment) Change evokes stress response and any change results from?: Change in environment
Loss of control
Dependence on others
How many stages of sleep are there?: Two stages of sleep

Non-Rapid Eye Movement
(NREM) has four stages

Rapid Eye Movement (REM)
has one stage only
Distraction does not work for pain?: False. It does work
(Diet Therapies) What is NPO?: Nothing by mouth
(Impact of Illness and Treatment) *Change evokes stress response: Example: hospitalization, surgery, family problems, lack of income, test.
What is Crisis?: It is an acute state of disorganization.

Occurs when the usual coping mechanisms no longer work.

Characterized by:
Extreme anxiety
Inability to function
Disorganized behavior

Crisis is usually time limited and intervention is necessary for a resolution.
What is undoing?: An unconscious attempt to make up for the past actions.
Pain is a real experience that needs to be treated?: True
What is enteral nutrition?: It provides luqiefied food and nutrients orally or into the GI tract through a gastrointestinal tube.
(Ex: tube feedings, nasogastric, peg tub (stomach), Jejunum tube.
What are the factors affecting elimination:: -age
-diet
-exercise
-medications
-personal elimination habits
-disease process
-emotional stress
Pain is a subjective experience?: True
What is urinary elimination?: Filters & excretes urine, this maintaining fluid, electrolytes, and acid-base balance.
What are the two types of elimination?: Urinary
Bowel
List the Food Guide Pyramid: -Bread, pasta, rice, cereal
(6-11 servings)
-Fruit
(2-4 servings)
-Vegetables
(3-5 servings)
-Meat, poultry, fish, dry beans, eggs, nuts:
(2-3 servings)
-milk, yogurt, cheese
(2-3 servings)
-Fats, oils, sweets
(use sparingly)
What is sleep?: It is a state of altered consciousness
Minimal physical activity
Slowing of the body's physiological process
Most clients report honestly on their perception of pain?: True
(Common Sleep Disorders) What is hypersomnia?: Excessive daytime sleep
(Common Sleep Disorders) What is narcolepsy?: sudden, uncontrollable desire to fall asleep during the day-time.
(Nutrition) What are the factors affecting nutrition?: -Age
-Lifestyle
-Culture
-Religious practices
-Economics
-Health status (dentures, short of breath)
What are the steps in assessment for elimination?: -Health history
-physical examination
(bladder palpate bladder, distended bladders? skin integrit, rash, infection, drainage?
-laboratory test
(UTI,occult blood, O/P, WBC,
CDIFF, Dip-stick)
-diagnostic tests:
*ultasound
*renal scan
*cystoscopy
*biopsy
*proctoscopy, sigmoidoscopy
*urinalysis(culture & sensitivity)
*X-ray-KUV
*Barium enema
What is a parental nutrition?: Nutrients entering the blood directly; infusion of a solution into the vein.
(TPN) Total parenteral nutrition
(PPN) peripheral parenteral nutrition (short-term) lower concentration & lower glucose.
Other nursing interventions to stress?: Stress management:
exercise
relaxaton tech./biofeedback
Guided imagery
Thought reframing or thought stopping
crisis intevention
What are the nursing interventions for stress?: Teaching-stress management techniques; how to reduce their own levels of stress.

Meet basic needs (Ex: cold, hungry, in pain)

Decrease environmental stimuli

Involve family/significant others.
(Diet Therapies) What are soft diets?: nuts, seeds, raw fruits & vegetables, fried, and whole grain foods avoided.
What is rest?: It is mental and physical.
State of relaxation, calmness
Examples: Lying down, reading a book, quiet walk.
(Diet Therapies) What are full liquid diets?: Any liquid
(Example: cream of wheat)
What type of diet would a person with Gastritis be on?: bland diet
Why is a client advised to increase the amount of fiber-rich foods in the diet?: Dietary fiber may prevent constipation and increase the desire to defecate.
What food or substances may irritate the bladder?: -cafeinated beverages, carbonated beverages, and acidic fluids (coffee and tea)
-aspartame
-citrus fruits and juices
-foods containing tomatoes or tomato-bases sauces
-chocolate
-greasy or spicy foods.
(Diet Therapies) What is a liberal bland diet?: free of chemical & mechanical food irritants (no acid, alcohol, caffeine, fried foods)
(Diet Therapies) What is Low-residue?: Reduced fiber and cellulose
(for client who has diverticulitis, Crohn's disease.
(Diet Therapies) Pureed is?: blenderized to smooth consitency (like baby food)
What are the parts of the nutritional assessment?: -Need to know diet history/ ability to chew/swallow
-24 hour recall of (intake)
was this normal for them or
Lab values for Albumin?: 3.5-4.8g/dl
lab values for hemoglobin?: M=14-18gm/dl
F=12-16gm/dl
If a patient has poor fitting dentures, what type of diet would they be on?: mechanical soft
What is the Wong/Baker scale?: It is used for 3-12 year olds.
Also developmentally delayed
Cultural differences.
The Wong/Baker scale has faces that rate the pain on a scale of 0-5
What is 1-10 numeric pain scale?: It is another type of scale that shows the intensity of pain on a scale.
0-no pain
5-moderate pain
10-worst possible pain
What is pain?: The presence of severe discomfort ad an uncomfortable sensation.

-It is the 5th vital sign.

-Pain can aler regulation.

-Pain is part of
sensory/perception/cognition
The nurse is the best judge of a client's pain?: False
Nursing Interventions for Sleep problems.: -Create a relaxing and comfortable environment.
-Establish a trusting nurse-client relationship.
-Appropriate nutrition
-Pharmacologic interventions (Ex: unrelieved pain)
-Relaxation techniques
-Client education.
What happens during (REM) rapid eye movement sleep?: Adult nightmares
flaccid muscles
dreams occur
20-25% of the sleep.
What are the nursing implications for panic anxiety?: Provide limits and structure, maintain client safety (both physical and psychological).
Sleep and Rest are part of the Regulation category. Sleep and rest varies with what?: Age level
Activit level
developmental level
cultural norms
(Stress and Illness) What are stress related disorders?: asthma, HTN, ulcer, hives, migraine headaches, GI distress.
Is anxiety healthy?: Yes. Some anxiety is healthy.
What are the nursing implications for mild anxiety?: This is an optimal time for client teaching because of heightened awareness and increased perceptual field.
What are the levels of anxiety?: Mild-Increased degree of alertness and increased vigilance.
Moderate-Subjective distress, decreased perception and attention
Severe-Increased subjective distress, selective attention,
distorted perception.
Panic-Major perceptual distortion, Immobilization; inability to function, impaired communication.
What is Denial?: Refuses to accept reality
Explain Anxiety.: It is the most common emotional (affective) response to stress. When feeling threatened (perceived or real)

Occurs on a continuum: some is healthy, until it impairs thinking & functioning.
When does anxiety become unhealthy?: When it impairs thinking & functioning.
What is rationalization?: Explains or justifies feelings or behaviors.
What is suppression?: conscious attempt to forget or store painful thoughts.
What is repression?: Unconscious way of forgetting painful thoughts.
What type of diet would someone with diverticulitis be on?: High fiber
Stess is the physiological reponse and anxiety is the ..............response: psychological
What are the stages of GAS (Selye's General Adaption Syndrome)?: Alarm-(Fight or Flight Response). Activation of the sympathetic Nervous System.
Resistance: Physiolocal forces are mobilized to increase resistence to stress. This is when adaptation occurs.
Exhaustion: disease, collapse,death.
What is Selye's General Adaption Syndrome (GAS)?: It is the body's reponse to stress (physiological). GAS is the same whether the stressor is real or imagined, present, or potential.

*The mind can imagine a stessor, and the physiological response will be the same.
Name dfferent types of stressors.: Internal (headache)
External (Well-Elder report)
Physical (Impacted tooth)
Pysiological (Diabetes)
Psychological (sick child, divorce)
Stressors are neither bad nor good because.....: The individual's perception determines if the outcome will be positive or negative
What determines if a stressor is bad or good?: Perception of the stress
What is stress response?: The psychological response. It is also anxiety.
What is anxiety?: It is a subjective response when a person feels threatened to their well-being; a diverse feeling of dread or apprehension.
What type of diet would someone with ulcerative colitis be on?: Low residue
(Diet Therapies) What are clear liquid diets?: No risidue liquids
(Example: 7-up, water, jello)
Liquids that you can see thru

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