Author Question: A patient is admitted for treatment of a home-acquired pressure ulcer. The patient is incontinent of ... (Read 51 times)

wrbasek0 · **on:** Jul 22, 2018

A patient is admitted for treatment of a home-acquired pressure ulcer. The patient is incontinent of urine and has Alzheimer disease. A Foley catheter is inserted. The nurse recognizes that the best way to break the infection chain is to:

a. discontinue the Foley as soon as possible.
b. wear a mask when working with the patient if she or he has a cold.
c. wear sterile gloves if there is a chance of contact with blood.
d. use surgical asepsis when handling body fluids.

Question 2

An older adult patient in a long-term care facility recently had a stroke after experiencing a myocardial infarction. The patient is not speaking or eating. The nurse notices an adverse change in vital signs.

When a patient is unable to resist the effects of a stressor, the nurse can identify this stage of the general adaptation system as: a. an alarm reaction.
b. the resistance stage.
c. the exhaustion stage.
d. a fight-or-flight response.

triiciiaa · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
To control or eliminate infection in reservoir sites, eliminate sources of body fluids, drainage, or solutions that possibly harbor microorganisms such as a Foley collection bag. Try not to work with patients who are highly susceptible to infection if you have a cold or other communicable infection. Another way of controlling the exit of microorganisms is by using standard precautions when handling body fluids such as urine, feces, and wound drainage. Wear clean gloves if there is a chance of contact with any blood or body fluids, and perform hand hygiene after providing care. Be sure to bag contaminated items appropriately.

Answer to Question 2

C
The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. The physiological response intensifies, but the person has so little energy left that adaptation to the stressor diminishes. The body can no longer defend itself against the impact of the event, and if the stress continues, it damages the heart along with other bodily organs and lowers resistance to illness. In the alarm stage, rising hormones result in an increased blood pressure, blood glucose levels, epinephrine and norepinephrine levels, heart rate, blood flow to muscles, oxygen intake, and mental alertness. This change in body systems prepares an individual for fight or flight and lasts from 1 minute to many hours. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm stage.