Fundamentals of Nursing Chapter 30 Review PP problem slides
What is Sordes?
A dark brown or blackish crustlike deposit on the lips, teeth, and gums of a person with dehydration resulting from a chronic debilitating disease
A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care? A) Use an antifungal powder on the client's feet if necessary. B) Carefully remove any corns or calluses that are present. C) Soak the client's feet for 15 to 20 minutes prior to cleansing. D) Avoid using soaps or commercial cleansers whenever possible.
Ans: A Antifungal foot powders may be used when indicated, and it is appropriate to use soap and/or cleansers when providing foot care. Corns and calluses should not be removed, and the nurse should avoid soaking the client's feet.
A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following? A) Facilitates oil distribution B) Cleans hair and scalp C) Removes excess oil D) Cleans the hair of dirt
Ans: A Brushing the hair facilitates oil distribution along the hair shaft more effectively than combing, as well as massages the scalp and stimulates circulation. Shampooing cleans the hair and scalp, helps get rid of excess oil, and cleans the hair of dirt. It provides a relaxing, soothing experience for the client.
Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene? A) Provide the client with an electric shaver. B) Provide the client with a firm bristled toothbrush. C) Do not allow the client to shower. D) Avoid massaging the client's back with lotion.
Ans: A Electric shavers are recommended when a client is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the client is more prone to bleeding, and the firm bristles may lead to bleeding. The client should be allowed to shower, unless there are other contraindications. A back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.
Which client is most likely to require hospitalization related to problems associated with the feet? A) A client with peripheral vascular disease B) A client with osteoporosis C) A client with asthma D) A client with diabetes insipidus
Ans: A Foot problems, particularly common in people with diabetes and peripheral vascular disease, often require hospitalization.
Which of the following is a recommended guideline when removing contact lenses from a client's eyes? a) Before removing hard or gas‐permeable lenses, use gentle pressure to center the lens on the cornea. b) If an eye injury is present, remove lenses immediately to avoid causing additional injury. c) Once removed, place both lenses in a cup and label it with the name of the client. d) If the contact lenses cannot be removed, they will have to be removed by the physician under sterile conditions.
Ans: A Gentle pressure should be used to center hard or gas‐permeable lenses on the cornea. Once removed, lenses should be placed in the appropriate container, identifying the right and left lens. If an eye injury is present, the lenses should not be removed because of the danger of causing an additional injury. If the lenses cannot be removed, they should be removed with the appropriate tool designated for the type of lenses in place.
A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition? a) Periodontitis b) Stomatitis c) Gingivitis d) Glossitis
Ans: A Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa
A nurse is assessing a client with dental problems including irritation, inflammation, and bleeding gums. The nurse recognizes that what condition may be contributing to these signs and symptoms? a) Sordes b) Plaque c) Periodontal disease d) Gingivitis
Ans: D The client has gingivitis, which develops when bacteria multiply and build up between teeth and gums, leading to irritation, inflammation, and bleeding. Bleeding gums are not a symptom of sordes, plaque, or periodontal disease. Sordes are dried crusts containing mucus and are common on the lips and teeth of unconscious clients. Plaque is a substance that supports the growth of mouth bacteria; it is composed of mucin and other gritty substances in saliva. Periodontal disease is a condition that results in the destruction of the tooth‐supporting structures and jawbone
The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A) Partial care B) As-needed care C) Self-care D) Complete care
Ans: A Morning care is categorized as self-care, partial care, or complete care. Clients identified as partial care most often receive morning care at the bedside, or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach. Clients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. Clients identified as complete care require nursing assistance with all aspects of personal hygiene. In additional to scheduled care, the nurse will offer care as needed.
While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? A) Periodontitis B) Plaque C) Halitosis D) Caries
Ans: A Periodontitis is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; and loose teeth.
A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? A) Wash hair daily B) Use dry shampoo C) Use oil-based shampoo D) Use anti-lice shampoo
Ans: A The client with a scalp infection should be advised to shampoo her hair daily with a mild shampoo. For occasional use, the nurse will use dry shampoos, which are applied to the hair as a powder. Other options include aerosol spray or foam. Anti-lice shampoos or oil-based shampoos are not used for fear of aggravating the infection.
A nurse is caring for an elderly client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, which of the following should the nurse do? a) Clean the dentures over a plastic basin or towel. b) Store the dentures in an open cup containing only mouthwash. c) Don gloves and free the dentures from the client's mouth. d) Avoid the use of a toothbrush to clean removable bridges.
Ans: A The nurse should clean the dentures over a plastic basin or towel to prevent breakage if dropped. The nurse should don gloves and use a dry gauze square or clean face cloth to grasp and free the denture from the mouth. The nurse should use a toothbrush to clean removable bridges and store the dentures in a covered cup containing plain water
An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine.
Ans: A To ensure proper perineal care, the nurse should cleanse to remove secretions and excretions from less-soiled to more-soiled areas. The nurse must also prevent direct contact with and any secretions or excretions by wearing clean gloves. The nurse should not use cotton cloth or tissues to clean the perineal area because that might lead to skin impairment. Older adult clients have sensitive skin, which may be easily impaired when cleaning. Because the client cannot do anything independently, providing him with a bed pan or a jar will not help.
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply a. It promotes the patient's sense of well-being. b. It prevents deterioration of the oral cavity. c. It contributes to decreased incidence of aspiration pneumonia. d. It eliminates the need for flossing. e. It decreases oropharyngeal secretions. f. It compensates for an inadequate diet.
Ans: A, B, E Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases (AACN, 2006; AACN, 2010). Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.
A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply a. Bathe the feet thoroughly in a mild soap and tepid water solution. b. Soak the feet in warm water and bath oil. c. Dry feet thoroughly, including the area between the toes. d. Use an alcohol rub if the feet are dry. e. Use an antifungal foot powder if necessary to prevent fungal infections. f. Cut the toenails at the lateral corners when trimming the nail.
Ans: A, C, E The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.
Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. Compare bilateral parts for symmetry. b. Proceed in a toe-to-head systematic manner. c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment. e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified.
Ans: A, C, F When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings
A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis frst, moving the washcloth in a circular motion from the meatus outward. f. In an uncircumcised male patient do not retract the foreskin (prepuce) while washing the penis
Ans: A, D, E Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.
Which of the following clients is at an increased risk for oral problems? Select all that apply A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client
Ans: A,B,C,D Clients at increased risk for oral problems include those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed. Clients who are mouth breathers, those who can have no oral intake of nutrition or fluids, those with nasogastric tubes or oral airways in place, and those who have had oral surgery are also at increased risk. Variables known to cause oral problems include deficient self-care abilities, poor nutrition or excessive intake of refined sugars, family history of periodontal disease, or ingestion of chemotherapeutic agents that produce oral lesions.
What care should the nurse take when providing foot care for a client with peripheral vascular disease? Select all that apply. A) Use an emery board to file toe nail edges B) Cut the toenails short C) Cut the nail in one piece D) Avoid cutting into calluses E) Cut the nails straight across
Ans: A,D,E The nurse caring for the client with peripheral vascular disease should use an emery board to file nail edges. These clients may have thick distorted nails that may be difficult to cut, but can be safely filed. The nurse should avoid cutting the nails too short or cutting into calluses to prevent trauma. The nurse should cut the nails straight across if possible, and cut in a few small pieces rather than one piece to prevent injury or skin breakdown.
When the nurse cleanses the client's leg during a bed bath, it will allow for ... a) Decreased restless leg syndrome b) Increased circulation c) Promotion of social interaction d) Assessment of pain
Ans: B Bathing increases circulation and helps maintain muscle tone and joint mobility.
On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what? A) Allow the client privacy B) Assess the client's safety C) Assess the client's pain D) Allow sufficient time
Ans: B Toileting often is associated with falls; the nurse must ensure the client's safety.
A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a. A patient who is taking antibiotics for chronic bronchitis b. A patient diagnosed with type II diabetes c. A patient who is obese d. A patient who has a nervous habit of biting his nails e. A patient diagnosed with prostate cancer f. A patient whose job involves frequent hand washing
Ans: B, C, D, F Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.
Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes? a. Using hydrogen peroxide b. Wiping from the outer canthus to the inner canthus c. Positioning him on the same side as the eye to be cleansed d. Using only one cotton ball per eye
Ans: C Positioning the patient on the same side as the involved eye discourages contamination of the other eye. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. Water or normal saline should be used for cleansing the eye of any discharge, and one cotton ball should be used for each stroke.
A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes
Ans: C Steps in the procedure include: Cover patient's chest with a towel or waterproof pad. Fill bath basin with warm (43ºC to 46ºC [110ºF to 115ºF]) water. Put on gloves. Moisten the area to be shaved with a washcloth. Dispense shaving cream into palm of hand. Apply cream to area to be shaved in a layer about 1/2-inch thick. With one hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin shaving. If shaving the face, shave with the direction of hair growth in downward, short strokes. If shaving a leg, shave against the hair in upward, short strokes. If shaving an underarm, pull skin taut and use short, upward strokes.
Which of the following factors does not affect personal hygiene practices? A) Culture B) Income level C) Health state D) Gender
Ans: D Personal hygiene practices vary widely among individuals and are affected by culture, socioeconomic status, spiritual practices, developmental level, health state, and personal preferences.
An unresponsive patient is wearing gas-permeable contact lenses. How would the nurse remove these lenses? a. Gently irrigate the eye with an irrigating solution from the inner canthus outward. b. Grasp the lens with a gentle pinching motion. c. Don sterile gloves before attempting the removal procedure. d. Ensure that the lens is centered on the cornea before gently manipulating the lids to release it
Ans: D The lens must be situated on the cornea, not the sclera, before removal. To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean, not sterile, gloves are used.
A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. a) Assist the client to a lateral position. b) Change the client's position every two hours. c) Arrange for suctioning to remove mucus. d) Apply mineral oil to the lips. e) Provide frequent mouth care.
Ans: a, c, e When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the lips of the client to overcome dryness caused by oxygen therapy. The client's position should be changed every two hours to promote comfort and circulation.
When performing health education regarding hygiene, the nurse should advise female clients to avoid the use of which of the following? Select all that apply. a) Routine douching b) Scented sanitary napkins c) Commercial soap d) Tampons e) Vaginal deodorants
Ans: a, e Douching has also been linked to vaginal irritation, bacterial vaginosis, pelvic inflammatory disease, and sexually transmitted infections (STIs). Deodorants to control odor around the vaginal orifice are unnecessary. The use of tampons, soap, and scented sanitary napkins is not inadvisable unless the client has a specific contraindication.
What is Halitosis?
Bad Breath
What are Caries?
Decay or crumbling of tooth or bone
What is pediculosis capitis?
Infestation of Lice on the head
What is Stomatitis?
Inflammation of the mucous membranes of the stomach
What is Glossitis?
Inflammation of the tongue
What does don mean?
To put on
What is Periodontitis?
inflammation of the tissue around the teeth, often causing shrinkage of the gums and loosening of the teeth.