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Chapter 039

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 39: Hygiene MULTIPLE CHOICE 1. The client has a red, raised skin rash. During the bath, the priority action of the nurse is to: 1. Assess for further inflammatory reactions 2. Discuss the body image problems created by the presence of the rash 3. Wash the skin thoroughly with hot water and soap 4. Moisturize the skin to prevent drying ANS: 1 The first action the nurse should take is to assess for further inflammatory reaction
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 3: !ygiene #$T%P$E C!%CE 1.The client has a red, raised skin rash. During the bath, the priority action of the nurse is to:1.Assess for further inflammatory reactions2.Discuss the body image problems created by the presence of the rash3.Wash the skin thoroughly ith hot ater and soap!. oisturi#e the skin to pre$ent dryingA%&:1The first action the nurse should take is to assess for further inflammatory reactions to determine if it is locali#ed or systemic. Discussing body image problems ould not be the priority nursing action. &kin should be ashed ith arm ater, not hot, as it may dry the skin. All soap should be rinsed ell so not to lea$e residue that may cause further irritation. The rash may be caused by moisture' thus moisturi#ing the skin ould not be appropriate. A lotion to help pre$ent itching may be applied.D():*+):-/0:AnalysisT/:%ursing rocess: lanning &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene2.The nurse is caring for a client ho has right9sided paralysis folloing a stroke. Which of the folloing factors ould be most likely to result in decubitus ulcer formation for this client1.oor nutrition2.(mmobility3.+educed hydration!.&kin secretionsA%&:2The client, ho has right9sided paralysis, is at increased risk for de$eloping a pressure ulcer because of immobility. When restricted from mo$ing freely, dependent body parts are e;posed to pressure, reducing circulation to affected body parts. Also, the inability to turn or change position increases risk for pressure ulcers. oor nutrition is a risk factor for de$eloping a pressure ulcer but not for this client. This client is not identified as ha$ing reduced hydration. &kin secretions increase the risk for de$eloping a pressure ulcer. 8oe$er, this client<s greatest risk factor is ha$ing impaired mobility.D():A+):-/0:*omprehensionT/:%ursing rocess: Assessment &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene osby items and deri$ed items = 2>>?, 2>> by osby, (nc., an affiliate of lse$ier (nc.  Test 0ank 3.The nurse delegates the hygienic care of a male client to the nursing assistant. (n re$ieing the client assignment, the nurse instructs the assistant to make sure to use an electric ra#or to sha$e the client ith:1.Thrombocytopenia2.*ongesti$e heart failure3./steoarthritis!.neumoniaA%&:1*lients prone to bleeding, such as the client ith thrombocytopenia, must use an electric ra#or. *lients ith congesti$e heart failure may use a ra#or blade to sha$e. *lients ith osteoarthritis do not ha$e to use an electric ra#or to sha$e. *lients ith pneumonia may use a ra#or blade to sha$e. (f the client is earing o;ygen, an electric ra#or should not be used as it could create a spark. /;ygen is flammableD():*+):-?3/0:AnalysisT/:%ursing rocess: lanning &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene!.The nurse delegates morning care to a ne certified nursing assistant. Which of the folloing actions by the assistant ould be e$aluated as appropriate1.lacing dentures in a tissue hile not orn2.*utting the client<s nails ith scissors3.@sing soap to cleanse the eye orbits!.Washing the client<s legs ith long strokes from the ankle to the kneeA%&:!To promote $enous return, the nursing assistant should use long strokes, ashing the client<s legs from the ankle to the knee and from the knee to the thigh. To pre$ent arping, dentures should be kept co$ered in ater hen they are not orn, and they should alays be stored in an enclosed, labeled cup ith the cup placed in the client<s  bedside stand. %ails should be clipped ith nail clippers, straight across and e$en ith tops of fingers, then filed. &cissors should not be used. The client<s eyes should be ashed ith plain ater as soap irritates eyes.D():*+):-3/0:AnalysisT/:%ursing rocess: lanning &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene.A B19year9old client ith diabetes mellitus has physician<s orders for meticulous foot care. Which of the folloing is the best rationale for the order1.The aging process causes increased skin breakdon.2.There is increased neuropathy ith this pathology that places the client at risk.3.The client probably has a history of poor hygienic care. osby items and deri$ed items = 2>>?, 2>> by osby, (nc., an affiliate of lse$ier (nc. 3?92  Test 0ank !.The loer e;tremities are difficult to see and therefore hard to maintain ith good hygiene.A%&:2Cascular changes associated ith diabetes mellitus reduce the blood supply to the feet. &ensation in the feet can also be reduced as a result of damage to the ner$es i.e., as ith diabetic neuropathyE. &ensory loss in the feet may result in undetected inFuries. These clients are especially at risk for the de$elopment of chronic foot ulcers. The best rationalefor meticulous foot care for this client is because of the risks associated ith the client<s diagnosis of diabetes mellitus. There is no indication the client has a history of poor hygienic care. oor $ision may contribute to difficulty in pro$iding foot care, but this client<s greatest risk for de$eloping a foot ulcer is diabetic neuropathy.D():*+):-3/0:AnalysisT/:%ursing rocess: Assessment &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygieneB.The client is unable to rest e$en after medication. The nurse decides to gi$e the client a  backrub. Which of the folloing strokes should the nurse use hen finishing the  backrub1.ong, firm strokes don the back 2.ight strokes hile mo$ing up the back in a circular motion3.Gneading mo$ements toard the sacrum!.*ircular motion upard from buttocks to shouldersA%&:1The nurse should end the backrub ith long, firm strokes don the back. The backrub is not finished ith light strokes hile mo$ing up the back in a circular motion. Gneading mo$ements toard the sacrum are done before ending the backrub ith long, firm strokesdon the back. The nurse should begin a backrub by massaging in a circular motion upard from buttocks to shoulders.D():A+):-B-/0:*omprehensionT/:%ursing rocess: (mplementation &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene.The nurse is instructing the client ith peripheral $ascular disease about daily foot care. The nurse<s instruction for the client includes:1.&oaking the feet  to 1> minutes each day2.)iling the nails into a cur$e shape3.@sing commercial corn remo$ers if needed!.Applying lamb<s ool beteen the toesA%&:! osby items and deri$ed items = 2>>?, 2>> by osby, (nc., an affiliate of lse$ier (nc. 3?93  Test 0ank Wrapping small pieces of lamb<s ool around toes reduces irritation of soft corns  beteen toes. *lients ith peripheral $ascular disease should not soak their feet. &oaking increases risk of infection caused by maceration of the skin. %ails should be filed straight across and sHuare. The client ith peripheral $ascular disease should not cut corns or calluses or use commercial remo$ers. The client should consult a podiatrist.D():*+):--3/0:AnalysisT/:%ursing rocess: (mplementation &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene-.To administer oral care to a semi9comatose client, the nurse should place the client in hich of the folloing positions1.+e$erse Trendelenburg2.8igh )oler<s ith the head to the side3.&ide9lying ith the head turned toard the nurse!.&upine ith the neck slightly forardA%&:3)or administering oral care, the nurse should place a semicomatose client on the side &ims< positionE ith the head turned ell toard the dependent side to facilitate drainageof secretions from the mouth. The semicomatose client should not be placed in re$erse Trendelenburg position for oral care. The semicomatose client should not be placed in thehigh9)oler<s position for oral care. The semicomatose client should not be placed supine for oral care, as oral secretions ould collect in the back of the pharyn;.D():*+):---/0:AnalysisT/:%ursing rocess: lanning &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 *omfort6ersonal 8ygiene?.The client is unable to perform self9care for the hair. The nurse is aare that hich of the folloing is accurate hen performing hair care1.0rushing the hair distributes the natural oils e$enly.2.@sing a hot comb may be $ery helpful for straight and oily hair.3.Cery tight braids keep the hair in good condition.!.&hampooing should be done daily.A%&:1)reHuent brushing helps to keep hair clean and distributes oil e$enly along hair shafts. A hot comb ould not be helpful for straight or oily hair. 0raids made too tightly can lead to bald patches. The freHuency of shampooing depends on a person<s daily routines and the condition of the hair.D():*+):-?>/0:AnalysisT/:%ursing rocess: lanning &*:%*45 test plan designation: hysiological (ntegrity60asic *are 7 osby items and deri$ed items = 2>>?, 2>> by osby, (nc., an affiliate of lse$ier (nc. 3?9!

Chapter 047

Jul 23, 2017

Chapter 048

Jul 23, 2017
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