Nursing Exam 2 Study Guide Vocabulary

Flashcards for Nursing Exam 2 vocabulary review.

Analyzing

Separating or breaking a whole into parts, a component of critical thinking.

Applying standards

Judging according to established personal standards, a component of critical thinking.

Discriminating

Recognizing differences, a component of critical thinking.

Information seeking

Searching for evidence, a component of critical thinking.

Logical reasoning

Drawing inferences, a component of critical thinking.

Predicting

Envisioning a plan, a component of critical thinking.

Transforming knowledge

Changing or converting the condition, nature, form, or function of concepts, a component of critical thinking.

Nursing Process

A client-centered approach involving assessment, diagnosis, planning, implementation, and evaluation.

Assessment (Nursing Process)

Collecting, organizing, validating, and documenting client data, including subjective and objective information.

Subjective Data

Symptoms or what the client says.

Objective Data

Signs or vital signs that can be seen, heard, felt, smelled, or observed by physical examination.

Nursing Diagnosis

Analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements.

Prioritization of Nursing Diagnoses

Using Maslow’s Hierarchy of Needs to prioritize problems or diagnoses.

Planning (Nursing Process)

Prioritizing problems, formulating goals, selecting nursing interventions, and writing nursing interventions.

Implementation (Nursing Process)

Reassessing the client, determining the need for assistance, implementing nursing interventions, supervising delegated care, and documenting nursing activities.

Evaluation (Nursing Process)

Collecting data related to outcomes, comparing data with outcomes, relating nursing actions to client goals, drawing conclusions about problem status, and modifying or terminating the care plan.

Two-Part Nursing Diagnosis

Includes the Problem (P) and Etiology (E), typically used for at-risk diagnoses.

Three-Part Nursing Diagnosis

Includes the Problem (P), Etiology (E), and Signs and Symptoms (S), typically used for actual diagnoses.

Defecation

The process of eliminating waste from the digestive system through feces or stool.

Normal Feces

Adult: Brown, Infant: Yellow, Formed, soft, semisolid, moist, Cylindrical shape, aromatic odor, Small amounts of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices

Abnormal Feces

Clay or white, Black or tarry, Red, Pale, Orange or green, Consistency Hard, dry, Narrow, pencil-shaped, or string like stool, Pungent Odor, Pus Parasites Blood Mucus Bacterial infection Large quantities of fatForeign objects

Soluble Fiber

Dissolves in water to form a gel-like material; examples include oats, peas, beans, apples, citrus fruits, and barley.

Insoluble Fiber

Promotes movement of material through the digestive system and increases stool bulk; examples include wheat flour, wheat bran, nuts, and vegetables.

Constipation

Decreased frequency of defecation with hard, dry, formed stools; fewer than three bowel movements per week.

Fecal Impaction

Mass or collection of hardened feces in the folds of the rectum with passage of liquid fecal seepage and no normal stool.

Diarrhea

Passage of liquid feces and increased frequency of defecation, more than 3 times per day with abdominal pain.

Clostridium difficile (C. diff)

A bacterium that produces mucoid and foul-smelling diarrhea, often affecting immunosuppressed clients or those on antimicrobial agents.

Steatorrhea

Fatty stool, often caused by pancreatitis or induced conditions.

Bowel Incontinence

Loss of voluntary ability to control fecal and gaseous discharges.

Flatulence

Presence of excessive flatus in the intestines, leading to stretching and inflation of the intestines; also known as gas.

Cathartics

Drugs that induce defecation.

Laxative

A mild agent that produces soft or liquid stools with abdominal cramps.

Enema

A procedure to prevent escape of feces during surgery, prepare the intestine for tests, or remove feces in instances of constipation or impaction.

Hypotonic Enema

Water moves out of colon after it stimulates peristalsis, causing water to move from the colon into interstitial space

Hypertonic Enema

Draws fluid from interstitial space into the colon.Small volume

Isotonic Enema

Considered the safest. Normal saline. No fluid movement into or out of colon.

Retention Enema

Introduces oil or medication into the rectum to soften feces and lubricate the rectum; retained for 1-3 hours.

Return-Flow Enema

Repeated instillation and drainage of 100-200 mL of fluid to stimulate peristalsis and expel gas; repeated 5-6 times.

Colorectal Cancer Screening

Includes fecal occult blood test, stool DNA test, flexible sigmoidoscopy, or colonoscopy to detect cancer.

Urination

Also known as micturition or voiding; the process of emptying the bladder.

Normal Adult Bladder Capacity

250-450 mL of urine.

Normal Daily Urine Output

1200-1500 mL.

Normal Urine Output Per Hour

30-50 mL.

Polyuria

The production of abnormally large amounts of urine by the kidneys, often several liters more than the client’s usual daily output, usually more than 50mL an hour

Oliguria

Low urine output, usually less than 500 mL a day or 30 mL an hour for an adult

Anuria

Lack of urine production

Urinary Frequency

Voiding more than 4-6 times a day.

Nocturia

Urinating two or more times a night.

Urgency

Sudden, strong desire to void.

Dysuria

Voiding is either painful or difficult.

Enuresis

Involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4-5 years of age

Urinary Incontinence

Involuntary leakage of urine or loss of bladder control.

BUN (Blood Urea Nitrogen)

10-20 mg/dL; reflects protein metabolism.

Creatinine Clearance

0.6-1.2 mg/dL; reflects muscle breakdown.

Specific Gravity (Urine)

1.005-1.030; indicates hydration status.

Catheterization

Introduction of a catheter into the urinary bladder.

Nutrition

The sum of all the interactions between an organism and the food it consumes.

Nutrients

Organic and inorganic substances found in foods that are required for body functioning.

NPO

Nothing by mouth

Clear Liquids

Provides hydration and supplies some carbohydrates for energy needs. Water, tea, coffee, broth, clear juice (grape, apple, cranberry) popsicles, carbonated beverages, and gelatin. – (No RED, post-op patients, duration of 1-2 days)

Full Liquids

Patients with GI disturbances. contains all clear liquids plus any food that are liquid at room temperature. Include soups, milk, milkshakes, puddings, custards, some hot cereals, juices, and yogurt. Difficult to obtain a balanced diet if needed for a longer period of time.

Mechanical soft (soft diet)

for clients with chewing difficulties (missing teeth, jaw problems, or extensive fatigue). Includes full liquids items plus soft vegetables and fruits, chopped, ground, or shredded meat; breads, eggs, and cheese.

Pureed

modified soft diet-blended diet. Any food item but altered by blending. (thinner consistency)

Thickened liquids

pudding, honey, nectar

Diet as tolerated

diet that works up the ladder, gradual increase in diet. (abdominal surgery patients.

Calorie restricted

for weight reduction (gastric bypass/weight loss)

Fat restricted

for clients with elevated cholesterol levels; may also be ordered for general weight loss

Hypoallergenic

patients that may have had allergic reactions to certain foods (ex milk)

Sodium restricted

for clients with HTN or fluid balance problems (diuretics, high BP, CHF- cardiac patient)

Dysphagia

Difficulty swallowing.

TPN (Total Parenteral Nutrition)

Delivered via venous catheter.

Enteral Nutrition

Nutrition provided through the gastrointestinal system via NG tube, G-tube, or J-tube.

NG Tube (Nasogastric Tube)

Inserted through the nostrils into the stomach.

G-Tube (Gastrostomy Tube)

goes into stomach (surgically placed),

J-Tube (Jejunostomy Tube)

goes into small intestine

Carbohydrates

45-65% of daily calories; major source of body energy.

Lipids (Fats)

Concentrated source and stored form of energy; provide 9 cal/g.

Proteins

Critical for growth and development of body tissues; provide 4 cal/g.

Vitamins

See Handout

water soluble vitamins

c and b (1-12) complex vitamin, can't store

fat-soluble vitamins

A,D,E,K. fat storage, risk for hyper/hypo

Albumin

Chronic (AisC); Pre-albumin is acute ;3.5 -5 ; the amount of protein in blood, binds to the cell and lets fluid in and out of it

Pre-Albumin

Acute (at risk for protein deficiency)

Fluid regulation

Intake – average adults drink about 1500mL/day (body needs 2500 mL/day).Thirst Mechanism – primary regulator of fluid intake, located in the hypothalamus

Sodium: 135 – 145 mEq/L (135 – 145 mmol/L)

controls and regulates water balance, found in the extracellular fluid, maintains blood volume/fluid volume

Potassium: 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L) ** THINK HEART**

intracellular- a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Helps to maintain acid-base balance, and contributes to intracellular enzyme reactions

Calcium: 9 – 10.5 mEq/dL

regulates neuromuscular function, including muscle contraction and relaxation, as well as cardiac function, strengthen bones/teeth, helps with blood clotting, helps with muscle contractions

Magnesium: 1.5 – 2.5 mEq/L

helps to regulate neuromuscular and cardiac functions, important for clients with cardiac disorders, necessary for protein and DNA synthesis within the cells.

Chloride: 98 – 106 mEq/L

functions with sodium to regulate serum osmolality and blood volume- (binds to Na), maintain fluid balance and acid base balance

Phosphate: 2 – 4.5 mEq/dL

functioning of muscles, nerves, and red blood cells. It is also involved in the metabolism of protein, fat, and carbohydrate. Phosphate is absorbed from the intestine. Binds to Calcium, helps maintain acid-base

Bicarbonate: 22 – 28 mEq/L

regulates acid-base balance as an essential component of the body’s buffering system. The kidneys regulate extracellular bicarbonate levels

Fluid volume deficit

hypovolemia (low fluids/ dehydration). Isotonic loss of water and electrolytes

Fluid volume excess

hypervolemia (increased blood volume) (fluid overload). Isotonic gain of water and electrolytes

Intravenous Solutions Isotonic Solutions

0.9% - NaCl (normal saline), Lactated Ringer’s (a balanced electrolyte solution)., 5% dextrose in water (D5W)

Intravenous Solutions Hypotonic Solutions

0.45% NaCl (half normal saline)

Intravenous Solutions Hypertonic Solutions

10% dextrose (D10)

Cane

COAL: Cane Opposite Affected Leg

Walker

Wandering Wilma’s Always Late: Walker With Affected Leg

Active ROM

Perform each ROM as taught to the point of slight resistance-Perform each exercise 3 times/ each series twice daily