NR304 / NR-304 Exam 2 Study Guide (Latest 2022 / 2023): Health Assessment II -, Study Guides, Projects, Research of Nursing

Download NR304 / NR-304 Exam 2 Study Guide (Latest 2022 / 2023): Health Assessment II - and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NR 304 Exam 2 Study Guide Chapter 21 Abdomen Structure and Function Abdominal Organs - Solid Viscera-doesn’t change shape, liver, spleen, ovary - Hollow Viscera-changes shape, stomach, intestine, bladder = Abdominal Muscles - Peritoneal Cavity-lines the abdomen Visceral Peritoneum-lines organs, stressed and inflamed with appendicitis andcholeycistytis Parietal Peritoneum-entire wall Structure and Function Abdominal Vasculature = Abdominal Aorta-listen for bruit for aortic aneurysm. Caused by pressure = Renal Arteries-stenosis from plaque Subjective Data = Appetite/wt. change - Dysphagia = Abdominal Pain = Nausea/Vomiting - Indigestion = Bowel Habits = Stool Assessment = Meds = Nutrition = Social Hx/Alcohol = Past Abdominal Hx = Stress = Family Hx Lifespan Considerations - Infants & Children: Feeding & eating habits, Gl function & nervous system maturation r/t toilet training = Pregnant Female: Nausea, constipation, heartburn (pyrosis), Linea Nigra = Older Adult: Muscletone, constipation, decreased peristaltic activity Objective Data Abdomen Inspection: Contour, symmetry, umbilicus, skin, pulsation Auscultation: Bowel sounds (4 quadrants), vascular sounds (bruit) Percussion: Tone (4 quadrants), *Ascites(fluid in the abdomen, becomes protuberant) flip pt to left-have tympana on right dull on left and vice versa assessment (p. 553). -want tympana due to gas Palpation: Light and deep palpation. Special procedures: Rebound tenderness (Blumberg at McBurney’s point) and Iliopsoas Sign-appendix, Murphy’s Sign-gallbladder Illeocecal valve RLQ—watery Terms to know... = Rectus Diastasis-separation of the rectus muscles midline. keep abdominal contents in place, pregnant women, body builders, abd. Surgery. = Cullen’s Sign-blue ring around umbilicus, internal bleeding = Borborygmi-really loud bow! sounds, hungry, negative sound when auscultating = Paralytic lleus-and not walking. Bowel obstruction. = Melena-Blood in stool, oxidized blood. Black tarry thick stools - Shifting Dullness- ascites patients = Distended/Distention-gas, ascites = Guarding of the Abdomen-Involuntary and voluntary = What is involved in the ongoing assessment of a client with an NG tube to suction...? WHY ...?—Drainage, aspirate gastric contents every time before you insert anything, turn off suction container when listening to bowel sounds Nursing Diagnoses = Ineffective Nutrition: lessthan body requirements r/t nausea and vomiting = Constipation r/t decreased fluid & fiber intake, bed rest, medications = Risk for ineffective health maintenance r/t lack of knowledge of need for recommended colon screenings = Pain, acute r/t inflammatory process What Predicts What?? = Hemoglobin 6.8 = Burning Sensation in epigastric region = No Appetite = Nausea/Vomiting Testyour knowledge Aclient reports abd. pain. How should the nurse proceed with the assessment? 1. Deep palpation 2. Assessing the painful area first 3. Assessing the painful area last with light palpation 4. Checking for warmth at the painful area When auscultating a clients abd. the nurse detects gurgles over the RLQ. What should the nurse suspect? 1. Decreased bowel motility * Stress-cough sneezed laugh to hard. Normal for aging * Urge-When you gotta go you gotta go Why are Kegal exercises taught? —to strengthen the bladder muscles. Men can also do Kegalsand it involves the prostate Treatable factors contributing to Incontinence—DIAPPERS Delirium Infection—Urinary, Symptomatic Atrophic Urethritis and Vaginitis Pharmaceuticals Psychologic Disorders Excessive Urine Output e.g. from Heart Failure or Hyperglycemia Restricted Mobility Stool Impaction oooooooono Terms to know = Polyuria-too much urine = Oliguria-little amount urine less than 30mls/hr - Anuria-no urinary output (Dialysis pts) = Dysuria-Painful urination = Retention-Post surgical patients, labor and delivery, spinal cord injuries = Hematuria-blood in urine - Nocturia-excessive night time urination Kidney Stones=Renal Calculi What should the nurse include when teaching this client on prevention of further calculi... ? RENAL CALCULI © T Incidence in Males Nausea & Vomiting © Agonizing Flank Pain May Radiate To: Groin Testicles Abdominal Area * Sharp, Sudden, Severe Pa May be i deperiding on stone ement) ¢ Hematuria © Dysuria * Urinary Frequency Chronic Renal Failure (CRF) ° Diagnosis Ultrasound IVP Renal Stone Analysis KUB (X-Ray) Serum: Calcium Oxalate Uric Acid * Risk Factors - Etioloay Infection Urinary Stasis & Retention immobility Dehydration T Uric Acid t Urinary Oxalate How is anemia and CRF connected? —Erythropoietin which is produced by kidneys. Blood cells not produced CHRONIC RENAL FAILURE (CRF - RENAL INSUFFICIENCY - * Headaches * | Ability to Concentrate Urine © Polyuria > Oliguria °TBUN& Serum Creatinine BUN=Blood urea nitrogen ° Edema © GFR - progressively decreases from 20 to 3O mi/min ¢ Mild Anemia eTBP ° Weakness & Fatigue The nurse is assessing a 51-year-old female experiencing an increased involuntary loss of urine with physical activity and sneezing. Her PMH is significant for abdominal surgery. What type of incontinence should the nurse anticipate this client is experiencing? 1. Urge 2. Functional 3. Stress 4. Reflex Aurine filled bladder is to percussion, while an empty bladder is. . 1. Dull, unavailable to percussion 2. Resonant, flat 3. Tympanic, dull Match the conditions listed with the appropriate description ____ Diminished urine output B ___Excessive voiding at night D ___Increased frequency & amount of voiding A ___ Visible blood in urine C a. Polyuria b. Oliguria c. Gross Hematuria d. Nocturia URINARY TRACT INFECTION: (U.T.1) Dipstick for DX: —> Leukocyte Estrace CYSTITIS: and Nitrates VA/C&S Erequency iok in older adults Urgency Suprapubic Fa Anti-Microbials Dysuria T Fluid Intake Hematuria Prevention Fever Confusion in Older Ad hing & Prevention ers Better Than Baths PYELONEPHRITI al Cleansing Flank Fain To Back” Dysuria fter Intercourse Fain At Costovertebral bial Therapy Angle Same S & S as Cystitis No Ferfumes, Etc. to Ferineal Area \ No Scented Toilet Paper —_— on. Empty Bladder Regularly Breastand Regional Lymphatics Chapter 17 Developmental Stages and Transitions = Infant: breast buds = Adolescent: Vocabulary = Prehn Sign-Torsion, or epididymitis. Lifttesticule and painis better, probably epididymitis. If it doesn’t relieve pain than torsion which is positive sign = Cryptorchidism-a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. = Transillumination (p. 703) pass strong light through (an organ or part of the body) in order to detect disease or abnormality. = Phimosis-A condition in which tight foreskin can't be pulled back over the head of the penis. = Paraphimosis-urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. It is important for clinicians to recognize this condition promptly, as it can result in gangrene and amputation of the glans penis Anus, Rectum, & Prostate Chapter 25 Developmental Stages and Transitions Benign Prostatic Hypertrophy or Hyperplasia (BPH) = Present in 1 our of 10 males >40 = Rectal exam (DRE) = Sxs: nocturia, dysuria, hesitancy, decreased urine stream = PSAat age 50 & earlier for those w/ family hx & African-American men 45 years of age Subjective Data = Usual bowel routine = Change in bowel habits = Rectal bleeding, blood in the stool = Medications = Rectal conditions - Family History = Self-Care screenings & care Objective Data Inspection & Palpation - Inspection of peri-anal area = Palpation of rectum: tone of sphincter, rectal wall = Palpation of prostate: size, shape, surface, consistency, mobility, sensitivity (p. 728) Health Promotion/Disease Prevention Teaching = Colorectal Cancer Screening pg. 730 = Fecal occult blood testing = PSA-screening for prostate cancer Alterations in Body system = Inflammation, hemorrhoids - Fissure, prolapsed rectum = Stool: Color (pg. 729): black, gray or tan, pale yellow, greasy, occult blood), consistency, constipation, fecal impaction Vocabulary = Pruritus ani-for children; from worms, come at night. Adult; usually from hemorrhoids = Hemorrhoids = Steatorrhea = Melena-dark black stool The Female Genitourinary System Chapter 26 Developmental Stages and Transitions Infants —genitalla Adolescents = Puberty & menarche - Tannerstages (p.739) Pregnant Woman = Goodell’s-when female is prego, cervix changes and becomes softer, when palpate it would be soft. & Chadwick’s sign-cervix turns blue Aging Woman = Menopause Subjective Data = Menstrual hx (LMP) = Obstetric hx: Grava-how many pregnancy the women has had& Para-how many births = Menopause = Urinary symptoms = Vaginaldischarge = Past history = Sexual Activity & Contraception use = STlcontact = Self-care behaviors Objective Data Inspection & Palpation = External genitalia = Internalgenitalia = Perineum = Anus & Rectum Health Promotion/Disease Prevention Teaching = Routine pelvicexams/PAP smears = STlrisk reduction = HPV Vaccine Alterations in Body System Abnormal Findings 764-765 - Herpes simplex virus: type 2 = Red rash - contact dermatitis = _HPV:Genital warts Vocabulary = LMP (last menstrual period) - Nulliparous-never been delivered baby = Amenorrhea-NMP = Cystocele/rectocele-Loose muscle tone, bladder comes down or rectum comes down. Cured surgically - Uterine prolapse-Uterus falls out of body Time to think as a nurse... Data: = 65 year-old female, “feeling pressure & discomfort “down there” whenever | have a bowel movement” = What are you thinking? = Whatarethe anticipated assessment findings?-uterine prolapse, hemorrhoids, cystole/rectocele = What are you worried about? Testyour knowledge When advising a female client regarding maintaining gynecological health, which statement is incorrect? 1. Void aftersexual intercourseto prevent UTI’s 2. Donot leave tampons in place for more than 8 hours at a time due to risk of toxic shock syndrome (TSS) 3. Wipe from front to back to prevent contamination of the vagina with fecal material 4. Douches should be used routinely Afemale client states that 2 weeks ago she had a urinary tract infection that was treated withan antibiotic. As part of the interview, the nurse must make sure to ask: Select all that apply 1. “Have you noticed any vaginal itching” 2. “Have you noticed any excessive vaginal bleeding?” 3. “Have you noticed any unusual vaginal discharge?” The nurse is inspecting the scrotum and testes of a 43-year-old male client. Which finding would require additional follow-up and evaluation? 1. The skinon the scrotum is shiny and smooth. 2. The left testicle hangs lower than the right testicle. 3. Thescrotum hasa darker pigmentation than the general skin color. During transillumination of the scrotum, the nurse assesses a mass that transilluminates with ared glow. This assessment finding is suggestive of: 1. Scrotal hernia 2. Scrotaledema 3. Orchitis 4. Hydrocele The congenital displacement of the urethral meatus on the ventral surface of the penis is: 1. Epispadias