MDC 1 Exam 1 Study Guide with Complete Solutions Maslow's Hierarchy of Needs - Correct Answer (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 - Correct Answer ask 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 - Correct Answer anticipate which patient may experience them and provide preplanned interventions pain - Correct Answer 5th vital sign cutaneous pain - Correct Answer superficial pain usually involving the skin or subcutaneous tissue visceral pain - Correct Answer pain originating in the internal organs and is non localized deep somatic pain - Correct Answer ligaments, tendons, bones, blood vessels, nerves radiating pain - Correct Answer starts at an origin but spreads to other locations referred pain - Correct Answer pain that is felt in a location other than where the pain originates phantom pain - Correct Answer pain or discomfort felt in an amputated limb Assessment of Elimination - Correct Answer -take patient history -monitor frequency, amount , and consistency 1 / 2
Interventions to prevent changes in elimination - Correct Answer adequate nutrition and hydration Interventions for patients with changes in elimination - Correct Answer -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 - Correct Answer involuntary urine loss with physical strain, sneezing, or coughing urge incontinence - Correct Answer loss of large amounts of urine accompanied with a strong urge to urinate overflow incontinence - Correct Answer small amounts of urine leak from a full bladder functional incontinence - Correct Answer the person has bladder control but cannot use the toilet in time unconscious incontinence - Correct Answer loss of urine when the person does not realize the bladder is full and has no urge to void intake - Correct Answer -measured in mLs -everything liquid output - Correct Answer stools and urine Assessment of Fluid Balance - Correct Answer -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 - Correct Answer drink 8 glassess of water a day and eat a balanced diet Interventions for fluid imbalance - Correct Answer fluid deficit: replace fluids
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