1. A number of factors influence a patient's personal preferences for hygiene. Because of this, it is impor- tant for the nurse to realize which of the
... [Show More] following? 2. 2. Social groups influence hygiene preferences and practices, including the type of hygienic products used and the nature and frequency of personal care. Which of the following developmental stages is most likely to be influenced by family customs? 3. 3. The patient received a diagnosis of diabetes 12 years ago. When admitted today, the patient is un- kempt and is in need of a bath and foot care. When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, what must the nurse understand? 4. 4. The nurse is caring for a patient who refuses "A.M. care." When asked why, the patient tells the nurse that she always bathes in the evening. What should the nurse do? 5. 5. Successful critical thinking requires synthesis of knowledge, experience, information gathered from pa- tients, critical thinking qualities, and intellectual and professional standards. Once the assessment has been done, what is it important for the nurse to under- stand? 6. 6. When the nurse provides hygiene for an older pa- tient, why is it important for the nurse to closely as- sess the skin? 7. 7. The nurse is bathing a patient and notices move- ment in the patient's hair. What should the nurse do? No two individuals perform hygiene in the same manner. Toddler. The patient's ill- ness may neces- sitate teaching of new hygiene prac- tices. Defer the bath until evening and pass on the information to the next shift. Critical thinking is ongoing. As people age, less frequent bathing may be re- quired. Use gloves or a tongue blade to in- spect the hair. 8. 8. When assessing a patient's skin, what does the nurse need to know? 9. 9. The nurse is caring for a patient who is immobile. Why is the nurse aware that the patient is at risk for impaired skin integrity? 10. 10. The nurse is caring for a patient who has diabetes mellitus, circulatory insufficiency, peripheral neuropa- thy, and urinary incontinence. What does the nurse know about patients with these conditions? 11. 11. The nurse is caring for a patient who has under- gone external fixation of a broken leg and has a cast in place. To prevent skin impairment, what should the nurse do? 12. 12. Of the following interventions, which would be the most important for preventing skin impairment in a mobile patient with local nerve damage? 13. 13. Of the following disorders, which is caused by a virus? 14. 14. The nurse is caring for a patient who is complain- ing of severe foot pain caused by corns. The patient states that she has been using oval corn pads to Moisture on the skin can lead to skin maceration. Pressure reduces circulation to af- fected tissue. They have de- creased pain sen- sation and are at increased risk of skin impairment. Assess all sur- faces exposed to the cast for pres- sure areas. During a bath, as- sess for pain. Plantar warts. Depending on severity, surgery may be needed to self-treat the corns, but they seem to be getting worse. remove the corns. What does the nurse explain? 15. 15. The patient receives a diagnosis of athlete's foot (tinea pedis). The patient says that she is relieved because it is "only athlete's foot" and it can be treated easily. What does the nurse explain about athlete's foot? It is contagious and frequently re- curs. 16. Fungi 16. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What causes this condition? 17. 17. The nurse is providing education about proper foot care to a patient who has diabetes mellitus. Why is this important? 18. 18. The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. What is the term for "bad breath"? 19. 19. The nurse is caring for an unresponsive patient who has a nasogastric tube in place for continuous tube feedings. Why does the nurse assess the pa- tient's oral hygiene? 20. 20. The patient is being treated for cancer with weekly radiation and chemotherapy treatments. The nurse is aware that the patient's oral mucosa needs to be as- sessed because radiation therapy and chemotherapy can have what effects? 21. 21. In providing oral care to an unconscious patient, what is an important action by the nurse? 22. 22. The nurse is teaching the patient about flossing and oral hygiene. Which of the following is the nurse's instruction? 23. 23. The nurse is caring for a patient who has head lice (pediculosis capitis). What should the nurse know about treating this condition? 24. 24. Scaling of the scalp accompanied by itching is known as which of the following? Foot ulcers are the most common pre- cursor to amputa- tion. Halitosis. Oral hygiene helps prevent gingivitis. Increase in likeli- hood of oral prob- lems. Rinsing the mouth and immediately suctioning the oral cavity. Flossing removes plaque and bacte- ria from the teeth. Head lice may spread to furniture and other people. Dandruff 25. 25. In finding pediculosis capitis (head lice) in a pa- tient, what would the nurse expect to observe? 26. 26. The nurse is caring for a patient who has multiple ticks on her legs and body. To rid the patient of ticks, what should the nurse do? 27. 27. The patient received a diagnosis of pediculosis capitis (head lice), was treated upon admission, and was re-treated 24 hours later, and yet the patient is still has an infestation. What should be the nurse's next action? 28. 28. The nurse is caring for an older patient with Alzheimer's disease who is ambulatory but requires total assistance with his activities of daily living (ADLs). The nurse notices that his skin is dry and wrinkled. What should the nurse do? 29. 29. A self-sufficient bedridden patient unable to reach all body parts needs which type of bath? 30. 30. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. She does this for which of the following reasons? 31. 31. The female nurse is caring for a male patient who is uncircumcised and not ambulatory, although he has full function of arms and hands. The nurse is providing the patient with a partial bed bath. What statement is true about perineal care for this patient? Pustules or bites behind ears and at the hairline. Use blunt tweez- ers and pull up- ward with steady pressure. Manually remove the lice using a fine-toothed comb. Reduce the num- ber of baths per week if possible. Partial bed bath. Washbasins can harbour Gram-negative organisms. It should be done by the patient. 32. 32. After the patient's bath, what should the nurse do? Not offer a back- rub for 48 hours after the patient undergoes coro- 33. 33. The nurse is providing a complete bed bath to a patient, using a commercial bath cleansing pack (bag bath). What should the nurse do? 34. 34. In providing perineal care to a female patient, how should the nurse wash? 35. 35. The nurse is providing perineal care to an un- circumcised male patient. When providing such care, how should the nurse treat the foreskin? 36. 36. Patients with diabetes mellitus need special foot care to prevent the development of ulcers. Knowing this, what is the nurse's action? 37. 37. The uncooperative patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, what may the nurse do? nary artery bypass surgery. Allow the skin to air dry. From pubic area to rectum. Retract the fore- skin and return it to its natural position when done. Requesting a con- sult with a nail care specialist. Use a padded tongue blade. 38. 38. How is basic eye care provided? The nurse cleans- es from inner can- thus to outer can- thus. 39. 39. The nurse is teaching a patient about contact lens care. The patient has plastic lenses, so what does the nurse instruct the patient to do? 40. 40. The patient complains to the nurse about a per- ceived decrease in hearing. When the nurse examines the patient's ear, she notices a large amount of ceru- Wash and rinse lens storage case daily. Apply gentle, downward retrac- tion of the ear men (ear wax) buildup at the entrance to the ear canal. canal. What should the nurse do? 41. 41. The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, the nurse instructs the patient to do which of the following? 42. 42. The patient is complaining of an inability to clear his nasal passages. How should the nurse instruct the patient? 43. 43. Of the following hearing aids, which interferes the most with wearing eyeglasses and using a phone? 44. 44. The use of critical thinking attitudes is necessary to design a plan of care to meet the patient's hygiene needs. Which of the following is considered to be a critical thinking attribute? Adjust the volume for a talking dis- tance of 1 m. To apply gentle suction with a pe- diatric bulb suction device. Behind-the-ear hearing aid. Curiosity 45. 45. Of the following patients, which one does the nurse A circumcised expect to perform perineal care independently? 46. A patient's personal preferences for hygiene are influ- enced by a number of factors. What must the nurse recognize? 47. The patients most in need of perineal care are those at the greatest risk for which of the following? 48. In addition to bathing, which of the following may best promote patient comfort? 49. For patients who experience conditions that threaten the integrity of the oral mucosa, which of the following is true? 50. What is the priority when providing oral hygiene to an unconscious patient? male patient who is ambulatory. No two individuals perform hygiene in the same manner. Acquiring an infec- tion. Back rub. More frequent mouth care is needed. Prevent aspiration 51. between 20°C and 23.3°C. Depending on the patient's age and physical condi- tion, the room temperature should be maintained at which of the following levels? 52. A patient with head and neck cancer has begun receiv- Mouth care every ing radiation therapy to the right side of the neck. Be- cause of the radiation treatments, the nurse includes which of the following interventions in the patient's plan of care? 53. The nurse is working in a nursing home and decides to implement a stringent mouth care protocol. What is the most important reason to establish this protocol? 54. After performing a home assessment, a home care nurse might make which of the following safety rec- ommendations to a family who will be caring for an older person after discharge from the hospital? 55. The nurse understands that providing a complete bed bath may have which of the following cardiovascular effects and thus plan for rest periods during the bath? 56. On examining the feet of an older person with type 2 diabetes, the nurse notices that his nails are long and thick. The patient says that the nails catch on his socks and asks the nurse to cut them. What is the most appropriate intervention for the nurse to imple- ment? 57. A patient receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care practices would the nurse recommend? four hours. Can reduce the in- cidence of pneu- monia in older per- sons. Set the water heater to a tem- perature that is not scalding. Increase in oxygen consumption. Calling the physi- cian and asking for a foot care consul- tation. Gently flossing be- tween the teeth once a day or more using un- waxed floss. 58. Placing them in a labelled, enclosed The nurse explains to a patient with a new set of upper and lower dentures that the dentures should be maintained daily by doing which of the following? 59. When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? 60. Hygiene care requires close contact with the patient. The nurse initially uses which of the following to pro- mote a caring therapeutic relationship? cup and covering them with water when they are not being worn. Compare one side of the body with the other. Communication skills. [Show Less]