Assessment Related to Hygiene and Personal Care
A nurse is initiating a care plan for a newly admitted hospitalized patient who is unable to perform basic ADLs independently. What intervention should be listed in the care plan?
Daily bed bath and assistance with hygiene, and as needed. The nurse should assist a patient with hygiene measures and bathing while hospitalized, and ensure that the patient has enough support and assistance when discharged.
The nurse notices that a patient with a complicated health history has halitosis when the patient speaks. The nurse knows that the patient's halitosis could be caused by_________?
Diabetes Poor oral hygiene medications Infections of the oral cavity
A nurse is developing a care plan for a chronically bedridden patient with a nursing diagnosis of Toileting Self-Care Deficit who is being discharged. Which goal is appropriate for this patient?
Locate appropriate homecare assistance. This is the most appropriate choice. The patient will need assistance in the home with using and cleaning bedpans, or possibly transferring to a commode. The nurse should focus on working with the case management team to obtain homecare services.
A nurse is reviewing the steps of performing a personal care assessment on a patient requiring bathing assistance. Which step should the nurse perform first?
Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice. The first step is to check the condition of the hair and scalp for infection and hygiene.
The nurse is caring for a patient who was involved in a motor vehicle accident (MVA). The patient did not sustain any oral trauma. How should the nurse document the normal assessment of this patient's oral cavity?
Pink and moist oral cavity without sores The oral cavity should be moist and pink, and should lack lesions or sores. These are normal findings.
The nurse is caring for a patient diagnosed with diabetes who has recently undergone an above-the-knee amputation (AKA). When assessing this patient's ability to perform self-care, the nurse should use what type of information?
Subjective data Objective Data Patient's answers
An older adult patient with arthritis has difficulty using his hands to button clothing, holding an eating utensil or toothbrush, and turning a door lock. In regards to this patient's discharge from the hospital to home, it is the nurse's responsibility to:
Assist the patient with community referrals. The nurse's role is to educate the patient about arthritis, and to educate the patient regarding the importance of performing ADLs independently, or with minimal assistance, as much as possible. If the patient is still struggling to perform ADLs, it is the nurse's role to implement resources to assist the patient. If a patient is unable to care for basic needs, the nurse assists the patient during hospitalization and consults with the provider to facilitate referral of the patient to appropriate community resources for assistance after discharge.
What are possible signs of poor hygiene?
Body odors tangled and matted hair excessively long and dirty toenails
The nurse is assessing a teenager's oral cavity as part of the admission assessment. Which finding, if observed during the assessment, should the nurse refer the patient to the dentist for further care?
Broken teeth Broken teeth are not treated by a general healthcare provider. The patient should be referred to a dental specialist.
The nurse is asking a patient hospitalized with acute pancreatitis questions about the patient's self-care capabilities. Which are examples of questions that the nurse may ask to assess the patient's ADLs?
Do you always make it to the bathroom on time? How often do you take a bath or shower? Can you bathe yourself without help?
A nurse is performing an initial assessment on a recently admitted patient. What finding warrants an immediate call to the healthcare provider?
Presence of pediculosis Pediculosis, or a lice infestation of the body hair, warrants immediate treatment and a phone call to the healthcare provider for orders. This is not a normal finding and requires treatment before it spreads to other patients and healthcare staff.
An immobile patient is running a fever. The nurse suspects the patient has a decubitus ulcer. The nurse observes the patient's skin for signs of infection, which may include what symptoms?
Redness Swelling Drainage
A nurse is caring for a patient with a severe infection of the gums. What is one possible nursing diagnosis based on the patient's "at risk" status?
Risk for altered nutrition The patient is at Risk for Altered Nutrition due to the likelihood of pain with eating or chewing. The nurse should consider a dietary consult, or switching the patient's diet to a soft or pureed diet. Incorrect
Based on the answers given during an initial health history, the nurse suspects that the patient has a fungal infection in his toenails. What physical exam findings would confirm this suspicion?
Thickening of the nail Thickening (and yellowish discoloration) of the toenail would confirm the nurse's suspicion of a fungal infection of the toenail. The nurse should contact the healthcare provider or podiatrist for medication orders.
The nurse is watching nursing students as they perform a chair bath. What activity, if observed by the nurse, should be corrected?
Washing the skin and hair before performing the assessment of patient's skin, hair, and nails. Washing the hair and skin before performing the assessment may cause the nurse to miss body odor, or oily, matted hair. These signs can give the nurse vital information about a patient's health status, or ability to perform self-care.
