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124 Cards in this Set

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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".
-Pureed-blenderized to smooth consistency (like baby food)
-low residue=reduced fiber and cellulose.(diverticulitis patients and crohn's disease)
-High fiber=raw veg & fruits, seeds, plant fiber, whole grains.(patients with constipation or diarrhea)
-liberal bland=free of chemical and mechanical food irritants(no acid, alcohol, caffeine, fried foods)
-fat controlled=reduce toal fat(cardiac patients & weight loss patients)
-sodium & potassium restriction=used for hypertension, cardiac and renal patients
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
(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".
(Example: Pureed, blenderized)
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.
(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".
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
abnormal for them?
-height, weight, physical appearance.
-lab date:
albumin(3.5-4.8g/dl)
hemoglobin (M=14-18gm/dl, F=12-16gm/dl)
bun=(10-20mg/dl)
Lab values for Albumin?
3.5-4.8g/dl
lab values for hemoglobin?
M=14-18gm/dl
F=12-16gm/dl
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
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?
low-residue diet
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
What type of diet would someone with diverticulitis be on?
High fiber
(Diet Therapies)
What are clear liquid diets?
No risidue liquids
(Example: 7-up, water, jello)
Liquids that you can see thru