NUR 1023 Exam 3 Study Guide
1. How would you describe a normal bowel habit?
It varies with each patient. It all depends on what the patient says is normal for them.
1. How would the nurse assess for fecal impaction?
The nurse will assess the patient’s rectum to feel for impacted stool. This is where patients have
difficulties pooping. You would glove up, lubricated your fingers and then disimpact patient by
pulling out the poop. This is called digital evacuation.
2. What are some key factors to effective communication?
•Ask open-ended question
•Be open and honest
•Restating what they say for clarification
•Make sure communication is both ways
•Ask patient what their preferred way of communication is
•Get an interpreter
•Making sure they are in the right environment to perceive information
being communicated to them
3. Describe interviewing techniques and give examples?
•Open-ended questions or comments
•Closed questions or comments
•Validating questions or comments
•Clarifying questions or comments
•Reflective questions or comments
•Sequencing questions or comments
•Directing questions or comments
4. What are some factors that may cause a message to be distorted?
•Language Barriers
•Misinterpretation what is said due to distraction (tv being too load, family members
in room making them uncomfortable)
•Irrelevant Questions
•Being in the wrong environment
5. What is the purpose of the outer layer of the skin?
Protection from foreign objects entering the body
6. Review how to stage a pressure Ulcer
•Stage 1- Bruised but not broken. Skin is still intact. None Blanchable.
•Stage 2- Broken skin. Red pink shallow wound. Very superficial
•Stage 3- Subcutaneous tissue is being exposed.
•Stage 4- Deep wound exposing the muscle bone and tendons
•Unstageable- Slouth, Necrosis (dead tissue) and Escar (you can accurately stage
an unstageable by debrief it)
•All pressure ulcer put patients at risk for infection (the higher the stage the high
the chance of infection) which can lead to Sepsis (Life threatening complication of
an infection)
•Tunneling and Undermining
7. What are the risk factors for developing pressure ulcers?
•Immobility
•Nutrition (Protein & Vitamin C & Zinc is important in the diet)
•Patients with illnesses such as diabetic patients, geriatric patient, patient with
stroke, head injury, incontinent (uncontrollable bowel or bladder movement)
8. Define polyuria, dysuria, nocturia, hematuria
•Polyuria- is constantly voiding (urination) Diabetics normally has this one
•Dysuria- painful or difficult urination. Patients who have a UTI, kidney stone, PBA, STI
•Nocturia- frequently urinating at night. Patients who are on diuretics who
takes medication at night/ wrong time
•Hematuria- blood in the urine. Patients who have Ovarian Cancer, Prostate
cancer, bladder or pelvis obstruction, prostate issue
If a patient is complaining that they can’t urinate, what would be the nursing
intervention?
Asses the patients for bladder distention, do a bladder scan, palpate first. If there is
urine retention move patient in a different position to see if it helps. If that doesn’t
work the next step is not for you to give patient fluid because they are already
experiencing urine retention you would encourage them to walk to the restroom and if
that doesn’t work then you would do the more invasive steps next like inserting a foley
9. What are the nutrients that play a big role in wound healing? Give some examples of
their food supplies
•Encourage food that are high in protein both complete (meat fish milk cheese)
and incomplete (beans, legumes, nuts) proteins
10. What are the different styles of communication? Give examples
•Verbal- asking questions to show you want to help the patient
•Non-verbal – actions, gestures, facial expression
•Interpersonal – amongst a group of people organization with the same goal •
Intrapersonal – conversation with one’s self
11. Define herniation, dehiscence, evisceration, and infection
•Infection- foreign micro organism that enters the body causes a negative reaction
•Evisceration- this is where the organs or intestine a protruding out of a surgical would
or just an opening in the abdomen
•Dehiscence- the is an open wound but the intestine or body contents remain
inside. Separation of a would or opening or reopening of a wound.
•Herniation- this is when a content of the body is protruding through the skin, but it
does not break the skin (e.g babies can have a herniated umbilical cord also herniated
disc)
12. Define serous, serosanguinous drainage
•Serous Drainage- this is the pale-yellow watery fluid or discharge from a wound
(from blisters or pimples)
•Serous Drainage- this is bloody water discharge
•Serosanguinous Drainage- this is the combination of serous and
serosanguinous drainage (e.g puss)
•Purulent Drainage is always a sign of infection when its observed coming from would.
It can be noticed to be discolored (green) and or it has a bad odor.
13. What is the purpose of a Penrose and a JP drain?
•Penrose Drain- used post- surgery to alleviate excess fluid from inside out by gravity
NOT NEGATIVE PRESSURE.
•Jackson- Pratt (JP) Drain- used post-surgery that alleviates excess fluid or fluid build
up and will only work if the bulb is compressed, NEGATIVE PRESSURE not GRAVITY
14. What are some interventions for bladder training for patients with incontinence?
•Ensuring that they do Kegel exercising
•Set specific time for the them urine
15. What are risk factors for developing psoriasis?
•Genetic
•Autoimmune disorder
•NO proper hygiene
•Sliver reddish Scabby, scaly skin breakout
•This is not constant and is normally triggered mainly by STRESS cause bad flare ups.
•Improper diet can trigger it as well
•But because STRESS is the pain trigger you should encourage patient to avoid
stressful situation, suggest STRESS reduction techniques
How does one get Contact Dermatitis?
They can get it by coming into contact that is irritating to one’s skin
16. What is tinea pedis?
•Tinea Pedis is the medical name for Athlete foot which is normally a fungus between
the toes sometime scaly and red/white.
17. Describe the classification of burns
•First Degree Burn- This is normally the most painful burn; it is normally superficial burn that
is on the dermis of the skin
•Second Degree Burn- this is when it the patient won’t feel as much burning because the
nerve endings are mostly burned away. This is burn that is associated with the epidermis of
the skin.
•Third Degree Burn- this is where the patient will not feel any bad because all the nerve
endings have been burned away however they are at great risk because the burn is
extremely deep. This normally affected the deepest layer of the skin
The biggest priority for burn patient is their Respiration or Airway. This is because they
have fluid shift. Patients can go into hypovolemic shock. When patients have a burn the
blood vessels vasodilate which makes them more permeable which allows any fluid
(blood or water) inside the vessel to shift of where it needs to be. Tricking the body into
thinking that there is no fluid available
Hypovolemic shock will be second priority
Infection would be third priority
18. What are some risk factors for hypovolemic shock?
•Absolute Hypovolemic Shock - losing excess blood volume from inside the body to
the outside of the body. Fluid shifting outside the body. (e.g Pooping Peeing or
Vomiting, Gunshot would, traumas, Diabetes insipidus)
•Relative Hypovolemic Shock - losing excess blood volume but not to the outside.
The fluid shifts from where it should be, but it does not go outside the body (e.g.
Internal Bleeding)
19. How do you care for a pt. with cellulitis?
Elevate the patient. IF contagious they must go on contact precautions
20. What do you document after assessing a stoma?
•(This means that stoma tissues are dead) Necrosis -bluish, greyish, dusty
•Stoma should be pinkish red, which means that it is still good to be used.
