VERIFIED SOLUTIONS 100% CORRECT
Analysis/Nursing Diagnosis: Oral Care - correct answer- •Risk
for Infection related to mouth lesions
•Impaired Dentition (caries) related to inability to afford dental
care
•Impaired Oral Mucous Membrane Integrity
•Planning Outcomes/Evaluation
•Planning Interventions/Implementation
Antiembolism Stockings - correct answer- •TED =
thromboembolic disorder hose
•Assessment: legs, feet and skin prior to application
•Laying for 15 minutes prior to application
•Leg: clean and dry
•Roll stocking
•Foot first
•Pull-up stocking
,•Smooth out stocking
•Create space for toes
§Remove daily
§Clean and dry legs daily
§Assess skin and circulation
§Document
§Wash every 3 days
§Dry stockings flat
Antiembolism stocks and sequential compression devices: Who
to Use - correct answer- Pre/Post Operative Patients
Immobile Patients
Limited Mobility Patients
Assisting Patients with Meals - correct answer- •Allow for
premeal rituals
•Allow for hygiene prior to meal
•Promote independence, provide privacy
•Demonstrate use of assistive devices
, •If in bed, place in highest tolerable position and adjust overbed
table
•If patient can feed themselves, prepare food
•If visually impaired identify locations
•If feeding patient sit down, do not rush, make eye contact
•Provide adequate time to chew and swallow
•Ask patient preference, serve small amounts
•Serve finger foods to promote independence
•Promote a relaxed environment
•Assist in providing hygiene
•Document
Barnes-Jewish hospital Stroke Dysphagia Screen - correct
answer- •Is Glasgow Coma Scale LESS than 13?
•Is there facial asymmetry/weakness?
•Is there tongue asymmetry/weakness?
•Is there palatal asymmetry/weakness?
•Are there signs of aspiration during the 3 oz water test?
Bathe patient at least ____________ a day. - correct answer-
once