MDC 1 Exam 1, Question well answered 2024.

Maslow's Hierarchy of Needs - ANSWERS(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization Assessment of Comfort Level - ANSWERSask patient if they are comfortable If they have physcial discomfort, assess level of pain and plan intervention if it's mental discomfort, have them describe the nature of the stress Interventions to prevent impaired comfort - ANSWERSanticipate which patient may experience them and provide preplanned interventions pain - ANSWERS5th vital sign cutaneous pain - ANSWERSsuperficial pain usually involving the skin or subcutaneous tissue visceral pain - ANSWERSpain originating in the internal organs and is non localized deep somatic pain - ANSWERSligaments, tendons, bones, blood vessels, nerves radiating pain - ANSWERSstarts at an origin but spreads to other locations referred pain - ANSWERSpain that is felt in a location other than where the pain originates phantom pain - ANSWERSpain or discomfort felt in an amputated limb Assessment of Elimination - ANSWERS-take patient history -monitor frequency, amount , and consistency Interventions to prevent changes in elimination - ANSWERSadequate nutrition and hydration Interventions for patients with changes in elimination - ANSWERS-Monitor pt for signs of fluid and electrolyte imbalance -adults experiencing urinary incontinence require frequent toileting -Patients with short term urinary retention require one or more catherization stress incontinence - ANSWERSinvoluntary urine loss with physical strain, sneezing, or coughing urge incontinence - ANSWERSloss of large amounts of urine accompanied with a strong urge to urinate overflow incontinence - ANSWERSsmall amounts of urine leak from a full bladder functional incontinence - ANSWERSthe person has bladder control but cannot use the toilet in time unconscious incontinence - ANSWERSloss of urine when the person does not realize the bladder is full and has no urge to void intake - ANSWERS-measured in mLs -everything liquid output - ANSWERSstools and urine Assessment of Fluid Balance - ANSWERS-health hx -monitor vitals especially pulse rate and quality -assess skin and mucous membrane for dryness and decreased turgor Interventions to prevent fluid and electrolyte imbalance - ANSWERSdrink 8 glassess of water a day and eat a balanced diet Interventions for fluid imbalance - ANSWERSfluid deficit: replace fluids fluid overload: restrict fluid Assessment of gas exchange - ANSWERS-health hx and assess patients breathing efforts and pulmonary function test interventions to prevent decreased gas exchange - ANSWERSteach infection control and to stop smoking interventions for someone with decreased gas exchange - ANSWERShaving them sit up Assessment of mobility - ANSWERSROM, gait and activity tolerance Interventions to prevent immobility - ANSWERS-determine who is at a higher risk -teach patients to do ROM every 2 hours Drinking fluids to prevent DVT -evaluate need for assitive device Interventions for immobility - ANSWERS-passive ROM -reposition patients every 2 hours -keep patient skin clean and dry Assessment for sensory perception - ANSWERS-conduct a health hx and determine factors for any sensory loss and perform cranial nerve test Interventions to prevent loss of sensory perception - ANSWERS-annual screening