Asia Williams Test 4 Review

Flashcards for Asia Williams' test review covering hair care, urinary and bowel needs, measurements, and pain management.

What does alopecia mean?

Hair loss

What is pediculosis pubis?

Infestation of the pubic hair with lice.

A resident’s hairbrush has sharp bristles. What should you do?

Report concerns about the person’s brush or comb.

You are shampooing a resident’s hair and notice scalp sores. What should you do?

Stop shampooing and report concerns about the person’s scalp sores to the nurse.

A patient has diabetes. Which health team members cut the person’s toenails?

Have a nurse or podiatrist cut the person’s nails.

Why is it important to know if a resident is taking anticoagulant drugs prior to shaving?

Anticoagulant drugs increase the risk of bleeding which can lead to excessive bleeding.

What is the difference between safety razors and electric shavers? How are they cleaned/disposed of?

Safety razors can cause cuts and nicks, while electric razors don’t. Safety razors are washed/rinsed, while electric shavers are taken apart, emptied, and brushed.

Who chooses how a person’s hair is styled? What if they have braids?

The residents choose how their hair is styled. If the residents have braids, you must ask for consent before taking them out.

If a resident has right sided weakness, how should you dress/undress them?

Dress on the weaker side first but undress on the stronger side.

What is the definition of urination/voiding?

The process of emptying urine from the bladder

What is the definition of Dysuria?

Painful or difficult urination

What is the definition of Polyuria?

Abnormally large amounts of urine

What is the definition of Oliguria?

Scant amount of urine; less than 500 mL in 24 hours

What is the definition of Nocturia?

Frequent urination at night

What is the definition of Hematuria?

Blood in the urine

Remind men not to place urinals on the .

Bedside table

When providing perineal care for incontinent persons, what should you remember?

Pat the area dry to prevent irritation, clean from front to back, change gloves and wash hands between cleaning different areas, use warm water and mild soap, and observe the skin for signs of redness, irritation, or breakdown.

How can normal urine be described?

Clear to amber, with a faint odor, with 1500 mL output per day.

What positions are included when assisting the patient onto the bedpan?

Supine, Fowler/semi-Fowler's, and side-lying positions.

After assisting with the bedpan or bathroom, what should the nurse aide assist the resident in doing?

Assist the residents with cleaning the perineal area, hand washing, and repositioning for comfort; ensure the call light is within reach and the environment is clean and safe.

Explain why it is important to make sure that the catheter tubing is not under the person.

Prevents pressure on the tubing, which could block urine flow, cause discomfort, or lead to skin breakdown, and reduces the risk of accidental dislodgement or damage to the catheter.

Explain why you should not hang a urine drainage bag on a bed rail.

Hanging the drainage bag on a bed rail raises it above the bladder level, which can cause urine to flow back into the bladder, increasing the risk of infection. The bag should be kept below the bladder to promote proper drainage.

A condom catheter is .

A soft sheath that slides over the penis and is used to drain urine

Never use to secure condom catheters and leave a inch space between the catheter and the tip of the penis.

Adhesive tape, 1

What are the rules for caring for urinary catheters?

Secure the catheter tubing to the thigh or abdomen to prevent pulling or dislodgement, keep the drainage bag below the level of the bladder to prevent backflow, ensure the tubing is free of kinks or loops to allow proper urine flow, and clean the catheter and surrounding skin during perineal care to prevent infection.

What are the rules for caring for urinary catheters continued?

Empty the drainage bag regularly, at least every 8 hours or when it is about one-third to half full, keep a closed drainage system to reduce the risk of infection, observe and report signs of infection, such as cloudy urine, fever, or pain, and provide fluid intake to promote urine flow and reduce sediment buildup.

How and when is catheter care performed?

Catheter care is cleaning the meatus and the first few inches of the catheter with soap and water, using a clean washcloth or disposable wipe, and moving from the meatus outward to prevent infection. Rinse and dry the area thoroughly. Catheter care is performed at least daily during bathing, after bowel movements, and as needed if there is soiling or irritation. Follow facility policy for specific timing.

What is the meatus?

The external opening of the urethra where the catheter is inserted or where urine exits the body.

How should a drainage bag be emptied?

Wash hands and wear gloves. Place a clean container under the drainage spout. Open the spout or clamp without touching the tip to avoid contamination. Allow urine to drain into the container. Close the spout securely and wipe it with an alcohol swab. Measure the urine if required, and dispose of it in the toilet. Clean the container, remove gloves, and wash hands. Document the amount, color, and characteristics of the urine, and report any abnormalities.

What is fecal impaction?

A hard, dry mass of stool lodged in the rectum or colon that cannot be passed naturally, often causing pain, discomfort, or obstruction.

Describe the role of diet in preventing constipation.

A diet high in fiber (from fruits, vegetables, whole grains) promotes regular bowel movements. Adequate fiber intake softens stool and makes it easier to pass, reducing the risk of constipation.

How does fluid intake affect bowel elimination?

Adequate fluid intake (6-8 glasses of water daily, unless restricted) keeps stool soft and promotes regular bowel movements. Insufficient fluids can lead to hard, dry stools, increasing the risk of constipation.

List 7 common causes of constipation.

A low fiber diet, ignoring the urge to have a BM, decreased fluid intake, inactivity, drugs, aging, and certain diseases.

What is fecal incontinence?

The inability to control the passage of feces and flatus through the anus.

List 4 actions that often produce flatus.

Exercise, walking, moving in bed, and left side-lying position.

When giving an enema, make sure the person is in .

Left semi-prone position or left side-lying position.

A resident has a colostomy. What is this? How do you care for colostomies?

A colostomy is a surgically created opening between the colon and the body's surface. Check the stoma and surrounding skin for redness, irritation, or breakdown. Empty the colostomy bag when it is one-third to half full to prevent leakage. Clean the skin around the stoma with warm water and mild soap, then pat dry. Apply a new pouch securely, ensuring a proper seal to prevent leaks. Observe and report changes in stool consistency, amount, or odor. Provide privacy and emotional support during care.

The person’s colostomy bag is distended from gas. What should you do?

Open the clamp or vent on the colostomy bag to release the gas. Ensure the bag is secure afterward and check for leaks or skin irritation.

When a person is having a bowel movement, which measures promote comfort and privacy?

Provide a bedpan, commode, or assist to the bathroom promptly to respect their needs. Ensure privacy by closing curtains/doors and covering the person appropriately. Stay nearby to offer assistance while allowing dignity and independence as possible.

What is the difference between flatulence and flatus?

Flatus is gas or air passed through the anus, while flatulence is excessive formation of gas or air in the stomach or intestines.

How can cramping be prevented when administering enemas?

Use the correct amount and temperature of the enema solution (warm, not hot or cold). Administer the solution slowly to avoid sudden pressure in the colon. Ensure the person is relaxed and in the proper position (left side-lying). Stop if the person reports discomfort and consult the nurse.

What should you do if pain is experienced during enema administration?

Stop the enema immediately, keep the person comfortable, and report the pain to the nurse.

What is C. Diff? How can it cause skin breakdown?

Clostridium difficile (C. Diff) is a bacterium that causes severe diarrhea and colitis, often due to antibiotic use disrupting gut flora. Frequent, watery diarrhea from C. Diff can irritate and damage the perineal skin, especially if not cleaned promptly. The moisture and acidity of the stool can lead to redness, irritation, or skin breakdown.

Unless otherwise ordered, take vital signs with the person .

Lying down or sitting.

What should you do if you are unsure of any vital sign measurement?

Retake the measurement and if still unsure, report to the nurse.

Rectal temperatures are not taken if the person:

Has diarrhea, has rectal problems, has had recent rectal surgery, is confused or agitated.

Oral temperatures are not taken if the person:

Is unconscious, has had recent facial/mouth surgery, has recent injury to the face, has sores/redness/mouth pain, is confused/agitated, has a history of seizures, is using oxygen, is a mouth-breather, or has a feeding tube.

A is an instrument used to listen to sounds produced by the heart, lungs, and other body organs.

Stethoscope

Which pulse is taken with a stethoscope?

Apical pulse

Hard-to-feel pulses are described as:

Weak or thready

The pulse is used for routine vital signs.

Radial

How is the radial pulse measured?

Place the first 2 or 3 fingers over the radial pulse site on the thumb side of the wrist, count the beats for 60 seconds using an analog watch with a second hand, and document the rate.

How long should you count an apical pulse?

60 seconds

What does respiration mean?

The process that supplies oxygen to cells and removes carbon dioxide from cells, involving inhaling and exhaling.

What is systolic pressure?

The pressure in the arteries when the heart contracts

What is diastolic pressure?

The pressure in the arteries when the heart is at rest between beats

What is Pulse rate?

The number of heartbeats per minute felt at an artery.

What does Axillary mean?

Pertaining to the armpit, a site for measuring temperature.

What does mL mean?

Milliliters, used to measure fluid volume

What is Apical pulse?

The pulse measure over the heart using a stethoscope

You must report any systolic pressure at or above and any diastolic pressure at or above .

140 mmHg, 90 mmHg

What are the guidelines for measuring Blood Pressure?

Ensure the resident is resting for at least 5 minutes before measurement. Position the resident sitting or lying down with the arm supported at heart level. Use a properly sized cuff that fits snugly around the upper arm. Place the cuff over the brachial artery, inflate to about 20-30 mmHg above expected systolic pressure, then deflate slowly (2-3 mmHg per second). Record systolic (first sound) and diastolic (last sound) pressures in mmHg. Report abnormal readings to the nurse immediately.

What are the guidelines for measuring respirations?

Observe the resident’s chest rising and falling without alerting them to avoid altering their breathing pattern. Count each inspiration and expiration as one respiration for 60 seconds using an analog watch with a second hand. Note the rate, rhythm, and depth of respirations. Document the respiratory rate and report abnormalities to the nurse.

When measuring weight and height, follow these guidelines:

Ensure the scale is calibrated and on a flat surface, help the resident remove shoes and heavy clothing, measure weight at the same time of day that the resident was last weighted (first weighted). Often done during the mornings make sure the resident stands straight against a wall or use a stadiometer for height record measurements in pounds/kilograms for weight and feet/inches for height, report abnormal change in weight or height to the nurse.

What are the normal values for Blood pressure?

Systolic 90-120 mmHg, Diastolic 60-80 mmHg

What are the normal values for Temperature?

Oral 97.6F-99.6F, Rectal 98.6F-100.6F

What are the normal values for Respirations?

12-20 breaths per minute

What are the normal values for Heart Rate?

60-100 beats per minute

What is acute pain? Chronic pain?

Acute pain serves a purpose by warning the body of a problem needing attention, with obvious discomfort and symptoms like pale, sweaty skin, and increased pulse, respirations, and blood pressure. Chronic pain is long-term pain lasting six months or more, with gradual onset, and the source may not be obvious, complicating diagnosis.

What effects can pain have on the body?

Giving up hope, depression, anxiety, withdrawal, change in appetite, decrease in activities, inability to sleep, restlessness, agitation, refusal to participate, suicide, negative effect on the immune system, and higher risk for injuries, falls, or accidents.

What are comfort measures that can be done to help relieve pain?

Warm or cold packs, massage, repositioning, soothing activities, meditation and spiritual support, supportive listening, gentle touch, music, soft lighting, decreased noise, conversation, and family involvement.

What fluids are measured when calculating intake?

Water, milk, coffee, tea, juices, soups, soft drinks. Including semi-liquids like milkshakes, ice cream, sherbert, custard, pudding, gelatin, and popsicles.

A patient is limited to 2000 milliliters (mL) of liquid intake per day. If the patient has 250 mL of juice for breakfast and 500 mL of milk for lunch, how much liquid can the patient have for the rest of the day?

1250 mL

If a person is 69 inches tall, how tall is the person in feet (ft) and inches (in)?

5 ft 9 in

A person drank 180 milliliters (mL) of coffee for breakfast, 240 mL of juice for lunch, and 250 mL of diet soda for dinner. What is the total liquid intake for these three meals?

670 mL

An 8-ounce serving of milk is equal to ____ milliliters.

240