Canadian Fundamentals of Nursing, 6th Edition

Canadian Fundamentals of Nursing, 6th Edition A number of factors influence a patient's personal preferences for hygiene. Because of this, it is important for the nurse to realize which of the following? - ANS No two individuals perform hygiene in the same manner. 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? - ANS Toddler. 3. The patient received a diagnosis of diabetes 12 years ago. When admitted today, the patient is unkempt 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? - ANS The patient's illness may necessitate teaching of new hygiene practices. 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? - ANS Defer the bath until evening and pass on the information to the next shift. 5. Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking qualities, and intellectual and professional standards. Once the assessment has been done, what is it important for the nurse to understand? - ANS Critical thinking is ongoing. 6. When the nurse provides hygiene for an older patient, why is it important for the nurse to closely assess the skin? - ANS As people age, less frequent bathing may be required. 7. The nurse is bathing a patient and notices movement in the patient's hair. What should the nurse do? - ANS Use gloves or a tongue blade to inspect the hair. 8. When assessing a patient's skin, what does the nurse need to know? - ANS Moisture on the skin can lead to skin maceration. 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? - ANS Pressure reduces circulation to affected tissue. 10. The nurse is caring for a patient who has diabetes mellitus, circulatory insufficiency, peripheral neuropathy, and urinary incontinence. What does the nurse know about patients with these conditions? - ANS They have decreased pain sensation and are at increased risk of skin impairment. 11. The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, what should the nurse do? - ANS Assess all surfaces exposed to the cast for pressure areas. 12. Of the following interventions, which would be the most important for preventing skin impairment in a mobile patient with local nerve damage? - ANS During a bath, assess for pain. 13. Of the following disorders, which is caused by a virus? - ANS Plantar warts. 14. The nurse is caring for a patient who is complaining of severe foot pain caused by corns. The patient states that she has been using oval corn pads to self-treat the corns, but they seem to be getting worse. What does the nurse explain? - ANS Depending on severity, surgery may be needed to remove the corns. 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? - ANS It is contagious and frequently recurs. 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? - ANS Fungi 17. The nurse is providing education about proper foot care to a patient who has diabetes mellitus. Why is this important? - ANS Foot ulcers are the most common precursor to amputation. 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"? - ANS Halitosis. 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 patient's oral hygiene? - ANS Oral hygiene helps prevent gingivitis. 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 assessed because radiation therapy and chemotherapy can have what effects? - ANS Increase in likelihood of oral problems. 21. In providing oral care to an unconscious patient, what is an important action by the nurse? - ANS Rinsing the mouth and immediately suctioning the oral cavity. 22. The nurse is teaching the patient about flossing and oral hygiene. Which of the following is the nurse's instruction? - ANS Flossing removes plaque and bacteria from the teeth. 23. The nurse is caring for a patient who has head lice (pediculosis capitis). What should the nurse know about treating this condition? - ANS Head lice may spread to furniture and other people. 24. Scaling of the scalp accompanied by itching is known as which of the following? - ANS Dandruff 25. In finding pediculosis capitis (head lice) in a patient, what would the nurse expect to observe? - ANS Pustules or bites behind ears and at the hairline. 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? - ANS Use blunt tweezers and pull upward with steady pressure. 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? - ANS Manually remove the lice using a fine-toothed comb. 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? - ANS Reduce the number of baths per week if possible. 29. A self-sufficient bedridden patient unable to reach all body parts needs which type of bath? - ANS Partial bed bath. 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? - ANS Washbasins can harbour Gram-negative organisms. 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? - ANS It should be done by the patient. 32. After the patient's bath, what should the nurse do? - ANS Not offer a backrub for 48 hours after the patient undergoes coronary artery bypass surgery. 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? - ANS Allow the skin to air dry. 34. In providing perineal care to a female patient, how should the nurse wash? - ANS From pubic area to rectum. 35. The nurse is providing perineal care to an uncircumcised male patient. When providing such care, how should the nurse treat the foreskin? - ANS Retract the foreskin and return it to its natural position when done. 36. Patients with diabetes mellitus need special foot care to prevent the development of ulcers. Knowing this, what is the nurse's action? - ANS Requesting a consult with a nail care specialist. 37. The uncooperative patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, what may the nurse do? - ANS Use a padded tongue blade. 38. How is basic eye care provided? - ANS The nurse cleanses from inner canthus to outer canthus. 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? - ANS Wash and rinse lens storage case daily. 40. The patient complains to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, she notices a large amount of cerumen (ear wax) buildup at the entrance to the ear canal. What should the nurse do? - ANS Apply gentle, downward retraction of the ear canal. 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? - ANS Adjust the volume for a talking distance of 1 m. 42. The patient is complaining of an inability to clear his nasal passages. How should the nurse instruct the patient? - ANS To apply gentle suction with a pediatric bulb suction device. 43. Of the following hearing aids, which interferes the most with wearing eyeglasses and using a phone? - ANS Behind-the-ear hearing aid. 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? - ANS Curiosity 45. Of the following patients, which one does the nurse expect to perform perineal care independently? - ANS A circumcised male patient who is ambulatory. A patient's personal preferences for hygiene are influenced by a number of factors. What must the nurse recognize? - ANS No two individuals perform hygiene in the same manner. The patients most in need of perineal care are those at the greatest risk for which of the following? - ANS Acquiring an infection. In addition to bathing, which of the following may best promote patient comfort? - ANS Back rub. For patients who experience conditions that threaten the integrity of the oral mucosa, which of the following is true? - ANS More frequent mouth care is needed. What is the priority when providing oral hygiene to an unconscious patient? - ANS Prevent aspiration Depending on the patient's age and physical condition, the room temperature should be maintained at which of the following levels? - ANS between 20°C and 23.3°C. A patient with head and neck cancer has begun receiving radiation therapy to the right side of the neck. Because of the radiation treatments, the nurse includes which of the following interventions in the patient's plan of care? - ANS Mouth care every four hours. 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? - ANS Can reduce the incidence of pneumonia in older persons. After performing a home assessment, a home care nurse might make which of the following safety recommendations to a family who will be caring for an older person after discharge from the hospital? - ANS Set the water heater to a temperature that is not scalding. 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? - ANS Increase in oxygen consumption. 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 implement? - ANS Calling the physician and asking for a foot care consultation. A patient receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care practices would the nurse recommend? - ANS Gently flossing between the teeth once a day or more using unwaxed floss. 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? - ANS Placing them in a labelled, enclosed cup and covering them with water when they are not being worn. When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? - ANS Compare one side of the body with the other. Hygiene care requires close contact with the patient. The nurse initially uses which of the following to promote a caring therapeutic relationship? - ANS Communication skills.