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Nursing Arts Assessment Test
Body Alignment - Answer-refers to the relationship of one body part to another part along a horizontal or vertical line Body Balance - Answer-is achieved when a wide base of support exists, the center of gravity falls within the base of support and a vertical line can be drawn from the center of gravity through the base of support Friction - Answer-physical force that opposes the direction you want to go Causes of injury - Answer-poor body position and movement, incorrect bed height, lifting technique Safe Lifting Technique - Answer--plan before you lift -keep the weight to be lifted as close to the body -bend at the knees -tighten the abdomen and tuck the pelvis -maintain truck erect and knees bent -avoid twisting Things to be aware of when lifting - Answer--know your limits -be aware of what areas you need to protect (previous injuries) -used good judgement of weight and clients ability to move or transfer
-use proper technique for the job and proper equipment When preparing to slide a client - Answer-turn, or transfer a patient, keep a wide sideways stance of wide walking stance with your hips and knees bent safe posture includes - Answer-keeping your back straight, shoulders back, elbows in and wrists straight When moving a patient - Answer-keep your body still and shift your weight through your legs and hips to move forward, backward or side to side Organs of the Upper Urinary Tract - Answer-Kidneys & Ureters Organs of the Lower Urinary Tract - Answer-Bladder, Uretha Length of urethra - Answer-4cm in women, 20cm in men Why females are more at risk for UTI - Answer-urethra is closer to the anus increasing the risk of contanimation Urination - Answer-AKA Micturition provess of bladder emptying (voiding). Volunatry and involuntary control. Muscular control in the bladder & pelvis help maintain continence Factors influencing Urination - Answer--psychological factors (stage fright) -sococultural factors -fluid balance -diagnostic exams / surgical procedures -pathological conditions
Urinary Diversion - Answer-divert ureters to the skin surface and form a stoma into a drainage bag Hospital acquired infection contributing factors - Answer-improper peri care, sterilization of catherter prior to insertion Assessment of Urinary Elimination includes - Answer--Nursing Health History -Physical Assessment -Assessment of Urine Parts of the Nursing Health History - Answer--Pattern of urination -symptoms of urinary alterations -factors affecting urination Parts of the physical Assessment - Answer--skin & mucosal membranes -kidneys (Flank pain) -Bladder (palpate for the bladder) -female/male perineum Assessment of Urine - Answer--intake and output -characterstics of the urine -urine testing Common Urine Tests - Answer--Urinalysis -Specific Gravity -Culture
Nursing Diagnosis related to urination - Answer--distrubed body image -urinary incontience related to skin break down -self care deficit, toileting -impared urinary elimination -urinary retention -risk for infected related to ... Types of urinary incontinence - Answer--Transient -urgency -stress -mixed -associated with chornic retenton -funtional multifactorial Urgency Incontinence - Answer-things that cant be reversed such as MS, Parkinsons Stress Incontinence - Answer-cough, laugh or sneeze etc. with releasing a bit of urine mixed incontinence - Answer-the combination of stress incontinence and urgency incontinence Functional Multifactorial Incontinence - Answer-cant get to the toilet for some reason be it cognitive, environmetal, chronic condition, condititions associated with aging) Implementing Urinary Care - Answer--Client Eduation -promoting regular urination
-assess limitations to sitting/laying -assess level of comfort -perform hand hygiene -provide privacy -side rail on oppostie side -raise bed -supine position Mobile Client use of bed pan - Answer--raise head of bed to 30 degrees -flex knees and lift hips -assist in lifting - trapeze Immobile client use of bed pan - Answer--lower head of bed -roll onto side -stabilize bedpan while client rolls onto bedpan -raise head of bed to 30 degrees unelss contraindicated -call bell within reach -lower bed -remove gloves care of indwelling catheter - Answer--maintain intactness of closed system -peri-care completed correctly -catheter bag below level of waist at all times -maintain stability of catheter -medical asepsis in emptying bag
method of emptying a catheter bag - Answer--wear clean gloves -place container under urine collection bag so spout does not touch it -cleanse drainage tubing with alcohol wipe prior ro re-inserting into plastic holder -document output and characteristics -all catheter/drainage bags should be emptied at least every 8 hours
