hygiene care

A nurse is teaching new graduates how the human body fights infection. When explaining humoral immunity, which cell type mediates this immune response?

B lymphocytes Humoral immunity involves specialized white blood cells called B lymphocytes that produce antibodies.

What cells are responsible for the production of antibodies?

B-lymphocytes B-lymphocytes are responsible for the production of antibodies.

During a patient's hospitalization, the nurse notes that the patient is unable to perform basic self-care. How should the nurse prepare the patient for discharge?

Arrange for regular homecare services with a nurse's aide. Arranging for a homecare helper is the best option in this situation. The nurse's aide would solely be responsible for helping the patient with ADLs in the home.

The cerebellum and inner ear are responsible for what?

Balance Balance depends on the inner ear and cerebellum.

The nurse is caring for a patient with trauma to the cerebellum. What problem should the nurse anticipate when getting the patient out of bed?

Balance and stability issues The nurse should anticipate balance and stability issues in the patient with cerebellar problems, as the cerebellum assists with equilibrium.

The nurse finds a patient to have missing teeth and refusing to wear dentures. Which food items should the nurse advise the patient to eat?

Banana Bananas are soft and easily chewed, even without the use of teeth. Gelatin Gelatin would be a good choice since there is no chewing necessary. Applesauce Applesauce is a food that requires little chewing, thus carries a decreased risk of choking.

During personal care, the nurse has the opportunity to assess the patient's integumentary system. What other activities of daily living allow for visualization of the patient's skin?

Bathing Bathing allows assessment of the skin over the patient's entire body.

Increased _____________________ results from the body's release of chemical mediators that allows fluid, cells, and protein to leak from surrounding blood vessels into the injured tissue.

Capillary permeability Increased capillary permeability results from the body's release of chemical mediators that allows fluid, cells, and protein to leak from surrounding blood vessels into the injured tissue.

Which conditions place the patient at a higher risk for infection?

Cardiovascular disease Cardiovascular disorders, or other chronic diseases can put the patient at an increased risk for developing an infection. Obesity Obesity has been linked to some types of skin infections located in skin folds Autoimmune disorder Autoimmune disorders are both chronic diseases and cause alterations in the immune system. In addition, some chemotherapeutic drugs are used to control immune function. All three of these factors can increase a patient's risk for infection.

A male adult who previously enjoyed running 5-6 miles per day now complains of a "grinding" sensation in the knee when he runs. He states that this has been a gradual problem which seems to be increasing in frequency. What could be responsible for this problem?

Cartilage Cartilage is within the joint to provide cushion. Lack of cartilage would create a "grinding" sensation as there is no cushion in the joint space.

Which term is used to describe a slightly movable joint?

Cartilaginous A cartilaginous joint is slightly movable.

the nurse is caring for a patient with a T-cell deficiency. Which immunity is this deficiency impairing?

Cellular immunity Cellular immunity involves T lymphocytes that defend against microorganisms the body doesn't recognize as its own, and so a low T- cell count would result in this immunity being impaired.

The patient's difficulties with posture are magnified by problems in what part of the brain?

Cerebellum Problems with posture are magnified in patients with cerebellar problems, as this part of the brain is responsible for maintaining equilibrium.

What injury is associated with breathing difficulties

Cervical spinal cord trauma Quadriplegia and breathing difficulties are associated with cervical cord trauma.

The rehabilitation nurse is caring for a patient with inability to move all four extremities. What type of injury is related to this?

Cervical spinal cord trauma Cervical spinal cord trauma is related to quadriplegia.

A post-surgical patient has a localized infection of the incision. Which symptom exhibited by the patient may indicate a systemic infection?

Chills Chills are a manifestation of a systemic infection commonly observed with high fevers.

What are common classifications of infection based on duration?

Chronic Infections are commonly classified as acute or chronic. Chronic infections develop and progress over time and may last months to years. Acute Infections are commonly classified as acute or chronic. Acute infections develop and run their course rapidly.

What are the primary responsibilities of the cardiopulmonary system?

Circulate blood throughout the body The cardiopulmonary system circulates blood throughout the body. Supply tissues with oxygen nutrients The cardiopulmonary system supplies bones, muscles and tissues with oxygen. Provide essential fluid for cell function The cardiopulmonary system supplies fluids that are essential for normal cell function.

An obese patient complains of itchy and uncomfortable skin. What interventions might the nurse expect to implement?

Clean the body with soap and water. Cleaning the body with soap and water eliminates build-up on the skin that can cause irritation. Apply anti-fungal powder to the itchy skin. Applying an anti-fungal powder can help reduce the irritation if infected. Assure all areas are cleaned with soap and water are thoroughly dried. The nurse should ensure that areas of the obese patient are cleaned and dried thoroughly to prevent fungal infections.

The nurse is caring for a patient who had a stroke that left him completely paralyzed. The patient is edentulous. How should mouth care be performed on this patient?

Clean the mouth with mouth swabs. The patient's mouth should be cleaned with mouth swabs. Moistening the patient's mouth is important to prevent bacteria from growing and for healthy gums.

After accidentally sticking oneself with a needle while inserting an IV, what should a nurse do first?

Clean the wound thoroughly with soap and water. The priority is to wash the wound thoroughly with soap and water and then have infectious disease blood tests drawn on herself and the patient involved. The incident should be reported to the physician and nurse manager.

Which areas are at risk for the development of pressure ulcers in the immobile patient?

Coccyx Areas at risk for pressure ulcers in the immobile patient include the coccyx, due to pressure and shear. Heels Areas at risk for pressure ulcers in the immobile patient include the heels, due pressure and friction. Elbows Areas at risk for pressure ulcers in the immobile patient include the elbows, due pressure and friction. Buttocks Areas at risk for pressure ulcers in the immobile patient include the buttocks, due to pressure when patient is lying in bed.

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.

Which complication associated with immobility affects the neurologic system?

Damage to the cerebrum of the brain Damage to the cerebrum of the brain directly affects the ability to ambulate and control movement, and affects the neurologic system.

Excessive amounts of dead, scaly skin on the scalp is called

Dandruff Dandruff is a scaling and flaking of the skin of the scalp.

What nutritional alteration is associated with immobility?

Decreased basal metabolic rate Immobility is associated with a decreased metabolic rate, due to a diminished activity level.

Which age-related skin issue increases the risk of pressure ulcers?

Decreased elastin Decreased elastin is a common age-related problem that directly contributes to an increased risk of pressure ulcers.

What contributes to an older adult patient's skin being wrinkled, thin, and dry?

Decreased elastin Decreased elastin is a normal finding related to the aging process, and causes an older person's skin to be wrinkled, thin, and dry.

What is the result of significant decrease in circulation and oxygenation?

Decreased nitrogen balance A significant decrease in circulation and oxygenation compromises nitrogen balance.

What complication can develop as a result of circulatory stasis and weakened calf muscles?

Deep vein thrombosis Circulatory stasis and weakened calf muscles can lead to the development of deep vein thrombosis.

Equilibrium

Dependent on the cerebellum and inner ear

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 Diabetes, and resultant kidney failure, are common causes of bad breath and halitosis. Patients who are at risk for diabetes, or who are known to have diabetes, should have their blood sugar checked. Poor oral hygiene Poor oral hygiene is one of the most common reasons for bad breath. The patient's oral hygiene practices should be discussed to look for gaps in knowledge. Infections of the oral cavity Bacterial and fungal infections can be one potential cause for bad breath. Resolving the infection often resolves the halitosis. Medications Certain medications can lead to chronic dry mouth and bad breath. The nurse should review the patient's current medications to see if any of them might be a potential cause.

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 Diabetes, and resultant kidney failure, are common causes of bad breath and halitosis. Patients who are at risk for diabetes, or who are known to have diabetes, should have their blood sugar checked. Poor oral hygiene Poor oral hygiene is one of the most common reasons for bad breath. The patient's oral hygiene practices should be discussed to look for gaps in knowledge. Infections of the oral cavity Bacterial and fungal infections can be one potential cause for bad breath. Resolving the infection often resolves the halitosis. Medications Certain medications can lead to chronic dry mouth and bad breath. The nurse should review the patient's current medications to see if any of them might be a potential cause.

How are the steps of the nursing process utilized?

Diagnose needs and plan goals The steps of the nursing process can be used to diagnose needs and plan attainable short-term and long-term goals. Assess individuals, families, and communities The steps of the nursing process can be used to assess individuals, families, and communities. Identify outcome criteria and implement interventions The steps of the nursing process can be used to identify outcome criteria, implement specific interventions, and evaluate degrees of goal attainment. Identify specific nursing interventions The nursing process not only involves the implementation of medical interventions, but the planning and implementation of nursing specific actions.

Determines number of each type of WBC

Differential white blood count (WBC)

What should the nurse look for in the patient who is having problems with equilibrium?

Difficulties with balance Problems with equilibrium affect the patient's ability to balance.

The nurse is caring for a patient who is being treated for an inner ear infection. What is an expected assessment finding?

Dizziness Equilibrium is related to the cerebellum and inner ear so an infection may cause the person to feel dizzy.

Which disorders decrease the body's ability to deliver oxygen and nutrients to body organs?

Heart failure Heart failure decreases the body's ability to deliver oxygen and nutrients to body organs and tissues. Peripheral vascular disease Peripheral vascular disease decreases the body's ability to deliver oxygen and nutrients to body organs and tissues. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease decreases the body's ability to deliver oxygen and nutrients to body organs and tissues.

In which condition is the heart is unable to pump enough blood to meet the body's demand?

Heart failure Heart failure is a complex condition in which the heart is unable to pump enough blood to meet the body's demand.

A nurse is caring for a patient in the telemetry unit who is complaining of a recent decrease in her ability to perform activities of daily living (ADLS) and routine exercise. Which conditions are possible contributing factors?

Heart failure Heart failure can create a diminished capacity for exercise. Peripheral vascular disease Peripheral vascular disease can create a diminished capacity for exercise. COPD COPD can create a diminished capacity for exercise.

What cells release interleukins and other substances that stimulate antibody production by B-cells and antigen destruction by other cells?

Helper T-cells Helper T-cells cells release interleukins and other substances that stimulate antibody production by B cells and antigen destruction by other cells.

Why is nail hygiene so important?

Helps prevent the spread of infection. Nail hygiene is important to help prevent the spread of infection. Nails may conceal dirt and microorganisms.

What is paralysis of one side of the body known as?

Hemiplegia Hemiplegia is paralysis of one side of the body.

Patients on bed rest are at risk for which problems?

Increased venous return Patients on bedrest are at risk for increased venous return, due to supine positioning. Decreased lung expansion Patients on bedrest are at risk for decreased lung expansion, due to pressure on the rib cage. Atelectasis Patients on bedrest are at risk for atelectasis, due to dependent positioning and limited lung expansion. Pneumonia Patients on bedrest are at risk for pneumonia, due to pooling of secretions in the lungs.

The nurse is tasked with catheter insertion on a patient of the opposite sex. The patient is of Middle Eastern descent. How should the nurse handle the initiation of the procedure?

Knock first, explain the procedure, and ask for the patient's comfort level. Knocking, explaining, and asking for comfort level are acceptable ways of showing sensitivity to your patient.

A nurse is caring for a patient with neurologic impairment. The health care provider has documented that the patient has lower extremity flaccidity. What does this mean?

Lack of muscle tone Flaccidity is a lack of muscle tone.

Which of these are examples of localized infections?

Large "pimple" A large "pimple" is specific to an area (skin) and indicative of localized infection. Swollen, red cuticle A swollen, red cuticle is specific to an area (skin) and indicative of localized infection. Pressure ulcer A pressure ulcer is an example of a localized infection.

Which of these conditions may result in right-sided hemiplegia?

Left-sided brain injury Left-sided brain injury results in right-sided hemiparesis or hemiplegia.

The rehabilitation nurse is caring for a patient with a history of cerebrovascular accident. The MRI revealed that the injury occurred on the right side of the brain. What are the expected impairments?

Left-sided hemiparesis Right-sided brain injury would cause left-sided hemiparesis.

Oral cavity alterations

Lessions, dry mouth, broken or missing teeth

What is a clinical manifestation of a systemic infection?

Lethargy Persistent lethargy can be a symptom of systemic disease, such as a urinary tract infection or septicemia.

What type of organism is usually seen when referring to pediculosis?

Lice Lice are the organisms associated with pediculosis.

Which component serves the purpose of connecting bone to cartilage?

Ligaments Bones are connected to cartilage by ligaments.

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.

What inhibits the growth of microorganisms by competing for necessary nutrients and secreting toxic substances that inhibit the growth of harmful organisms?

Normal flora Normal flora inhibits the growth of microorganisms by competing for necessary nutrients and secreting toxic substances that inhibit the growth of harmful organisms.

The nurse is caring for a patient who has had an incontinence episode of both urine and stool, and needs to perform her skin assessment for her shift. Place the nurse's next steps in order.

Note that the patient has soiled the pad. Clean the patient's skin. Assess the patient's skin, noting any redness or breakdown. Place skin protectant paste on the patient's skin.

An immobile patient had been admitted to the unit following a fall out of bed. The patient is coughing up thick secretions. What action should the nurse take next?

Notify the health care provider that the patient may have pneumonia. The nurse should notify the health provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.

Integumentary and Mucous Membrane Alterations Related to Hygiene and Personal Care

Now that you have considered this information about integumentary and oral cavity alterations, let's put it all together. Alterations, such as ulcers, incisions, wounds, decreased sensation, alopecia, and infection can affect the structure and function of the integumentary system. The oral cavity includes mucous membranes of the lips, the gums, the cheeks, the tongue, and the hard and soft palate. When these are not properly cleaned, it can cause a myriad of alterations that may affect other parts of the body. Proper oral hygiene must be performed to prevent additional problems, such as halitosis, infections, or other systemic involvement. Personal care alterations can affect the patient's self-care abilities, such as bathing and oral hygiene. These alterations can occur due to illness, recent surgery, immobility, and cognitive dysfunction. Diversity considerations must be considered when assessing patient self-care abilities. The nurse should understand how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.

Which method was developed to advance the nursing profession and how nurses provide care to all patients?

Nursing process The term, nursing process, allowed nursing leaders to develop a formal process for providing nursing care for all patients, and has advanced the professional and autonomous image of the nurse.

The cardiopulmonary system is responsible for supplying the rest of the body with what?

Nutrients The cardiopulmonary system supplies the body with oxygen and nutrients. Chemicals The cardiopulmonary system supplies the body with chemicals that are essential for normal cell function. Fluids The cardiopulmonary system supplies the body with fluids that are essential for normal cell function.

What is the Subjective Global Assessment (SGA) tool used to predict?

Nutrition-related complications The SGA tool predicts nutrition-related complications.

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.

What nursing activity starts the assessment of a patient's mobility?

Observing the patient Assessment of the patient's activity level starts with observing the patient.

A nurse is caring for a patient with osteoporosis. In which type of patient is this condition most prevalent?

Older Asian female Osteoporosis is more prevalent in the older adult population and in Caucasian and Asian women.

Which patient would least likely be at risk for skin ulcers?

One with Alzheimer's disease A patient with low mental awareness is at risk for ulcers; however, this option is the least at risk as compared with the other options.

When reviewing a patient's chart, the nurse notes the documentation of a pressure ulcer. What would the nurse expect to find upon assessment?

Open wound over the sacrum Pressure ulcers can be open wounds and the sacral area is a particularly high-risk area for pressure ulcer development in bedridden patients.

The nurse is caring for a patient with oral cavity sores. Which food item would the nurse advise the patient to avoid?

Orange slices Orange slices contain citric acid, which would cause discomfort in a patient with open oral cavity sores.

Which musculoskeletal diseases are more prevalent in the older population?

Osteoporosis Osteoporosis is a disease in which bones deteriorate, and is a disease that is prevalent in the older adult population. Osteoarthritis Osteoarthritis causes cartilage breakdown, and is a disease that is prevalent in the older adult population.

An older adult male is on prolonged bedrest, related to lower extremity trauma. Which cardiopulmonary condition is a concern in this patient?

PVD PVD is a disturbance in the venous system caused by venous stasis, immobility, inflammation, and prolonged bedrest.

Which type of immunity does administration of an antibody-rich substance such as immunoglobulin provide?

Passive immunity Passive immunity can be obtained through transfer of antibodies from one person to another by injection of an antibody-rich serum.

What type of immunity does a newborn baby receive from its mother's breast milk?

Passive immunity Passive immunity occurs when a person receives antibodies that were produced in another body, such as a baby consuming its mother's breast milk.

While caring for a patient at high risk for developing an infection, the nurse observes that the patient's ESR remains elevated for the past three days. What can the nurse consider based on these results?

Patient is responding poorly to therapy. The nurse can determine from the elevated ESR levels that the patient is not responding well to therapy. Patient is experiencing inflammation and may have an infection. Elevated ESR levels indicates that the patient is experiencing inflammation and may have a systemic infection.

A nurse is reviewing drug resistance with nursing students. The nurse knows that they understand the concept when they make which statement?

Patients are at higher risk for developing serious, untreatable infections. Patients are at a higher risk for developing serious infections without any medications that are able to control the infection.

Which are strategies of collecting key patient assessment data?

Performing a general assessment Performing a general assessment including the patient's susceptibility and appearance is one strategy of collecting key patient assessment data. Assessing the patient's vital signs Assessing the patient's vital signs is a strategy to collect key patient assessment data. Obtaining a thorough history Obtaining a thorough history of the patient is one strategy of collecting key patient assessment data.

Which of these precautions is the most effective way to minimize the spread of infection?

Performing routine hand washing before and after attending every patient. Routine hand washing with soap and water or an alcohol-based cleanser is the most effective way of preventing the spread of infection.

Which condition is related to venous stasis?

Peripheral vascular disease Peripheral vascular disease is a disturbance in the venous system caused by stasis of blood.

What is the process in which special types of leukocytes engulf and ingest bacteria and other pathogens?

Phagocytosis Phagocytosis is the process in which special types of leukocytes engulf and ingest bacteria and other pathogens.

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.

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.

What aids the beginning of chemical digestion?

Saliva Saliva secretes mucus, enzymes, and a watery fluid that forms saliva and begins the chemical breakdown of food and fluids.

Which of these indicates a localized infection?

Tooth with an abscess A tooth with an abscess would be limited to the dental pocket and indicates a localized infection.

Which of these substances contain antigens?

Toxins An antigen is any substance that provokes an adaptive immune response. Antigens include protein molecules on the surface of nonliving substances, including toxins. Pathogens Antigens, which are protein molecules that provoke an adaptive immune response, are found on the surface of pathogens. Chemicals Antigens, which are protein molecules that provoke an adaptive immune response, are found on the surface of chemicals

What is a function of adaptive immunity?

Triggering the production of lymphocytes Triggering the production of lymphocytes is a function of adaptive immunity.

Which nursing actions are examples of good hygienic foot care?

Trimming toe nails regularly The nurse is responsible for the care of the patient's nails including trimming, but must use critical thinking/clinical judgment in deciding which patient's nails are safe to trim. Washing feet with soap and water Washing feet helps reduce dirt and microorganisms that may lead to infection. Checking for swelling or discoloration Regularly checking for swelling or discoloration helps with early identification of potential problems.

When assessing a newly admitted patient, the nurse observes a red area on the patient's sacrum. What action should the nurse implement?

Turn the patient on the right side. Turning the patient on the right side is taking the pressure off of the sacrum and an intervention that the nurse should implement. Assess to see if the red area on the patient's sacrum blanches. Assessing to see if the red area on the patient's sacrum blanches is important to implement. If the site blanches, hopefully, the pressure being taken off of the sacrum will allow the site to heal. If the site does not blanche, the patient has a deeper tissue injury than the epidermis.

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer?

Two

The nurse is caring for a patient with cerebellar damage related to traumatic brain injury. What are expected side effects of this condition?

Uncoordinated movement Coordination is controlled by the cerebellum and damage would cause uncoordinated movement. Poor balance The cerebellum is responsible for equilibrium. Cerebellar damage would interfere with balance. Inability to remain upright Cerebellar damage may interfere with the body's ability to maintain posture. Unsteady gait Cerebellar damage may cause unsteady gait.

Halitosis

Unpleasant breath odor

Lack of proper body alignment can lead to what condition?

Unsteady gait Lack of proper body alignment can lead to an unsteady gait.

Typically, normal flora is not present on what type of body sites?

Sterile sites Typically, normal flora is not present on sterile body sites.

When creating a brochure for parents to help prevent pediculosis, which statement should the nurse include?

"Assist your child with checking for head lice regularly." A child is not able to independently check head for lice. The parent should do this regularly to promote early detection and treatment. "Have the child tell you if his head itches." The child should be instructed to tell the parents if head itches or is uncomfortable. The parent should then know to check the scalp for signs of lice. "Look for any patches of hair loss." Hair loss is associated with frequent scratching of the scalp, which can be a sign of pediculosis.

Which statement, if made by the patient regarding oral hygiene, would indicate the need for further education?

"Changing my toothbrush every year is important." A toothbrush should be replaced every three months or more often if the bristles get damaged. After that, it becomes ineffective in plaque removal.

A patient with chronic arthritis is having difficulty with teeth brushing. Which statement best shows how the nurse can help with sensitivity in mind?

"I know you're used to doing this alone. If you let me help, we can get it done quickly." This statement shows the most sensitivity towards the patient, while still giving a balance of independent and dependent functioning.

Which statement, if made by a chemotherapy patient, indicates the need for further education?

"I will scrub with hard brushes when I wash my head." The patient should avoid scrubbing with hard brushes, due to the risk of irritation and infection.

What statement by the nurse best expresses the proper approach to perineal care to a patient of the opposite sex?

"If at any time you feel uncomfortable, please let me know." This statement shows sensitivity towards a client of the opposite sex.

The nurse is asking the patient about how far the patient walks each day. The patient asks the nurse why that information is important. What is the nurse's best response?

"It gives us information about your activity and agility." The question provides data about a patient's activity and agility.

While caring for a comatose patient, a nurse asks a new graduate nurse what the Braden Scale is used for. Which response indicates that the new nurse understands the purpose of the Braden scale?

"It is a standardized tool used to identify patients at risk for pressure ulcers." The Braden Scale is a standardized tool used to identify patients at risk for pressure ulcers.

A nurse is reviewing personal care procedures with nursing students. The nurse knows they understand the importance of hygiene when they make which statement?

"Personal care is the best time to perform a skin assessment." The nurse should use personal care as an opportunity to perform a full assessment of the skin and accessory organs, as well as enhance the nurse-patient relationship through communication.

The nurse is providing patient education to a family member who is wondering what is causing her mother's infection. Which response would be the most appropriate?

"Your mom's infection is caused by an invasion of foreign bacteria or viruses that her body is unable to fight." An infection is caused by foreign bacteria, viruses, or other microbes that invade the body. If the immune system is not able to fight off the invading microbes, an infection will result.

A patient complains of chronic bad breath. What is the best advice to help the patient?

Stop smoking Tobacco use is one of the leading factors contributing to halitosis and is the best way to help him eliminate his bad breath.

What is the primary purpose of appropriate hand hygiene?

To prevent or control the transmission of infectious microorganisms from any source

The WBC count differential is the proportion of each type of WBC out of_ cells.

100 The WBCs exist in specific proportions throughout the blood. Measuring the proportion of the different WBC types in a sample group of 100 cells is called the WBC differential. Abnormal values can indicate the presence of an infection.

A microorganism is considered to be resistant if it cannot be stopped by the use of____ or more antibiotics.

2 A microorganism is considered resistant if the use of two or more antibiotics is unable to stop its growth. These antibiotics may be used either sequentially or simultaneously.

To help prevent ulcers, a nurse turns the patient every _____ hours

2 It has been found that to prevent pressure ulcer development, a patient should be turned and repositioned once every two hours. Repositioning too frequently can lead to irritation and discomfort. Changing position and pressure points less frequently can increase a patient's risk for skin breakdown and pressure sores.

What is the normal range of the white blood cell count for adults?

4500 to 10,500 cells/mm3 The normal adult white blood cell count is 4500 to 10,500 cells/mm 3.

The nursing process includes ___ steps.

5 The nursing process includes five steps: assessment, diagnosis, planning, implementation, and evaluation.

A nurse is responsible for all new admissions on a particular floor. Which patient should be the priority for an available private room?

A 37-year-old female with complications from chemotherapy. The 37-year-old patient is severely immunocompromised due to her chemotherapy treatment, and history of a chronic illness. In addition, nausea and vomiting caused by the chemotherapy has likely rendered the patient nutritionally compromised as well. She should be placed in the private room.

Which patient is most at risk for skin ulcers?

A frail paraplegic A frail paraplegic best represents someone with a high risk for spending most of his or her time in bed. This significantly increases the risk for skin breakdown and ulceration.

Which patient is at the greatest risk for hospital-acquired infection (HAI)?

A middle-age female patient receiving chemotherapy for lung cancer

A nurse manager receives word that a patient with West Nile virus will be admitted to the floor. In which room should the patient be placed?

A standard room - no isolation precautions are needed West Nile virus is an infection that is transmitted through the bite of an infected mosquito and is not contagious through airborne, droplet or contact modes of transmission. No isolation precautions are needed.

A patient tells the nurse she had chickenpox as a child and should not be susceptible to the virus causing chickenpox. Which type of immunity does the patient attain?

Active immunity Active immunity involves antibody production in response to an antigen, such as the virus that causes chickenpox.

Patient reports shortness of breath and fatigue while performing activities of daily living are indicative of which problem?

Activity intolerance Patient reports of shortness of breath and fatigue while performing activities of daily living are signs of activity intolerance.

The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities.

Adaptable The adaptable characteristic of the nursing process refers to nursing care plans being developed for patients in any care setting, as well as for targeted populations and communities.

What piece of clothing is best to remove when looking for excoriations?

Adult diaper A patient wearing an adult diaper indicates the skin is exposed to stool and urine, which is a major risk factor for excoriation and skin breakdown.

Place the steps in the order as they should occur after a nurse is accidently exposed to a blood-borne pathogen.

After accidental exposure to a blood-borne pathogen, such as through a needle stick, the priority is to thoroughly wash the wound with soap and water and apply an anti-bacterial ointment as necessary. Next the exposed nurse should have baseline infectious disease bloods drawn (namely for Hepatitis B and C, and HIV). If the source of the exposure is known, the patient should be tested as well. Finally, the exposed nurse should begin medical prophylaxis as soon as possible and repeat testing per hospital protocol.

A nurse is caring for an older adult woman with advanced dementia who is incapable of self-care. However, the patient insists on brushing her own teeth at bedtime this evening. How should the nurse proceed?

Allow her to brush her teeth with supervision. Supervising the patient while brushing her teeth, then helping her finish what was missed, is a good compromise. It allows the patient to have her psychological need for independence met, while completing the physical task.

The nurse is caring for a patient who has been in bed for several days after surgery. The nurse has orders to get the patient out of bed to a chair. What action should the nurse take first?

Allow the patient to dangle. The first action the nurse should take to get the patient out of bed is allow the patient to dangle.

What psychosocial condition is associated with the inability to interact with the environment?

Alteration in self-concept Alteration is self-conceptis associated with the inability to interact with the environment.

The nurse is caring for a patient with PVD. Which nursing interventions are expected to be included in the plan of care?

Ambulation PVD may be caused by prolonged bedrest so, ambulating the patient would be part of the plan of care. Lower extremities elevated Pooling of blood further exacerbates PVD so the patient should have extremities elevated in the sitting position.

A patient is diagnosed with pediculosis. The nurse explains to the family that this is:

An infestation of the body hair with lice Pediculosis is an infestation of the body hair with lice. The scalp is most commonly affected, but any area of the body that contains hair can be affected.

The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step.

Analytical The analytical characteristic of the nursing process refers to nurses asking analytical questions throughout the process, which demonstrates the use of critical thinking.

Match the nursing process characteristics to the definition. Nurses use critical thinking for each step of the nursing process.

Analytical The nursing process changes over time in response to patient needs. Dynamic The nursing process helps ensure that patient care is well planned. Organized Nurses evaluate patient outcomes to determine effectiveness. Outcome-oriented

A nurse is working in a pediatrician's office and examining a young child with a viral infection. The mother demands antibiotics for the child's infection. How should the nurse respond?

Antibiotics won't treat a viral infection and may worsen drug resistance. Antibiotics will only kill infectious bacteria and not viruses. Prescribing them in this situation will only worsen the potential for drug resistance.

Which nursing actions should take place immediately prior to ambulation of a patient who has been immobile to prevent injury to the patient?

Assess the patient for dizziness. Immediately prior to standing, the patient should be assessed for dizziness. Assess the patient's ability to stand unassisted. Immediately prior to standing, the patient should be assessed for the ability to stand unassisted. Dangle the patient's legs on the side of the bed. Immediately prior to standing, the patient's legs should be dangled on the side of the bed.

Which techniques can the nurse use to assess the patient's hygiene and personal care?

Assessing the patient's scalp for oiliness The nurse observes the patient for oily, matted, tangled hair. Asking the patient about dry skin and rashes To better assess the patient's skin, the nurse asks the patient if dry skin, rashes, skin changes, or lesions exist. Using a chair bath to assess the patient's skin for turgor and warmth During a chair bath, the nurse takes this opportunity to objectively assess the skin for changes using inspection and palpation to note the color, texture, turgor, warmth, and integrity of the skin and related structures. Washing the patient's hands to observe the condition of the fingernails Washing the patient's hands and feet allows the nurse to observe the fingernails and toenails for color, thickness, cracking, odor, or deformity.

Place the steps of the nursing process in the order in which each should occur.

Assessment Diagnosis Planning Implementation Evaluation The nursing process consists of five steps. The first step is assessment, where the nurse gathers important data through observation, patient history, and physical exams. The second step is diagnosis, where the nurse analyzes that information and creates a specialized nursing diagnosis that reflects the data. The third step is planning. During this step, the nurse prioritizes the diagnoses and plans focused interventions based on those diagnoses. The fourth step is implementation. The nurse carries out the planned interventions during this step. The final step is evaluation, where the nurse determines whether the interventions were effective in meeting patient goals and addressing identified diagnoses.

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

When turning a patient to place a slide board, where do the assistants stand

At the side of the bed to which the patient will be turned

A patient who has been immobile at home for the last three months is admitted to the hospital. Which problems should the nurse anticipate finding when the patient is examined?

Atrophy of the muscles The nurse should anticipate finding atrophy of the muscles as an effect of immobility on the musculoskeletal system. Contractures The nurse should anticipate finding contractures as an effect of immobility on the musculoskeletal system. Joint contracture can occur within hours of disuse. Pain with joint movement The nurse should anticipate finding pain with joint movement as an effect of immobility on the musculoskeletal system. Pain occurs from moving joints that have not been moved or are contractured Joint stiffness The nurse should anticipate finding joint stiffness.

A nurse is training new staff to assess a patient's activities of daily living (ADLs). What should the nurse advise the new staff to include in their assessment?

Bathing The ability of the patient to bathe or shower independently is one example of an ADL. If a patient is unable to bathe independently, the nurse can arrange for homecare services to help the patient in the home. Toileting Toileting is an essential ADL. If a patient is unable to use the bathroom independently, the patient is at greater risk for infection, skin breakdown, incontinence, and other skin issues related to poor hygiene. Dressing It is important for a patient to be able to dress—and undress—independently.

A patient has a surgical wound with staples. The provider has given an order for the patient to shower with the incision covered, but the patient has refused twice. How can the nurse advise the patient?

Bathing cleanses microorganisms from the skin and lessens the chance of infection. If the nurse teaches the patient, the patient may understand the rationale for the provider's order, and may be more motivated to shower as ordered.

Laceration

Bleed according to size, type, and location; example, surgical incision

Puncture

Bleed depending on the size, type, and location; causing internal bleeding

What are possible signs of poor hygiene?

Body odors Body odors may be an indication of poor bathing practices, although there may be other reasons for body odor, including change in diet or diabetes. Tangled and matted hair Tangled and matted hair can be an indication of poor grooming and the inability of the patient to perform self-care. Excessively long and dirty toenails Excessively long and dirty toenails are an indication of poor grooming. The nurse should ask if the patient is unable to perform this activity.

Decreased physical exercise contributes to what symptoms?

Bone fragility Decreased physical exercise and lack of weight-bearing exercise contribute to bone fragility. Deterioration Decreased physical exercise and lack of weight-bearing exercise contribute to deterioration. Loss of strength Decreased physical exercise and lack of weight-bearing exercise contribute to loss of strength.

The ________ score is used to assess skin integrity and the risk for skin breakdown.

Braden The Braden score is used by nurses in the inpatient setting to evaluate the patient's skin and risk for skin breakdown. It should be documented at least daily, and in some facilities, once a shift. The Wong-Baker Facial Grimace Scale is a pain scale. The Morse Fall Scale measures the patient's fall risk. The Holmes-Rahe Social Readjustment Rating Scale measures stress.

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.

What should the nurse implement regarding the oral cavity and hygiene?

Brush the teeth and rinse the mouth with a fluoride, non-drying mouthwash after meals and at bedtime. The nurse should help the patient brush the teeth and rinse the mouth with a fluoride, non-drying mouthwash after meals and HS. This helps to keep the gums, teeth, and oral cavity healthy. Eat a balanced diet and reduce snacks. The nurse should encourage the patient to eat a balanced diet and to reduce snacks. This helps keep the gums, teeth, and oral cavity healthier

Which statements best describes a fecal impaction?

Buildup of hardened feces in the lower intestine A fecal impaction is best described as a buildup of hardened feces in the lower intestine.

Which cardiopulmonary condition is caused by chronic airway inflammation?

COPD COPD is a progressive lung disease associated with chronic inflammation of the airways.

A patient asks the nurse what dietary supplements to take to reduce the chance of developing brittle bones later on in life. What is the best response by the nurse?

Calcium Calcium is important in the production and maintenance of bone tissue. Inadequate intake of calcium or impaired calcium metabolism increases bone fragility. Vitamin D Vitamin D is important for the development of bone and tissue formation because of its collaborative efforts with calcium.

Which mineral is stored in bone and assists with maintenance of phosphorous?

Calcium Calcium is stored in the bone and assists with maintenance of phosphorous.

A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan?

Calcium should be taken with vitamin D to increase calcium absorption. Vitamin D is required for calcium metabolism.

the first stage of the inflammatory process, causes an increased blood flow to the site of the injury.

Capillary dilation Capillary dilation, the first stage of the inflammatory process, causes an increased blood flow to the site of the injury.

Number of RBCs, WBCs, platelets, and retculocytes

Complete blood count (CBC)

Which factor may contribute to the spread of health care associated infections (HAIs)?

Complications after routine surgical procedures Complications after routine surgical procedures are one way that HAIs are spread.

Which nursing diagnosis best displays sensitivity towards the needs of the patient and family?

Compromised family coping Being aware of how a patient and family cope with illness shows sensitivity.

Inactivity, decreased appetite, and decreased fluid intake can lead to what problem with elimination?

Constipation Inactivity, decreased appetite, and decreased fluid intake leads to constipation.

Posture and gait

Controlled by the nervous system

What nursing skill is essential when utilizing the nursing process?

Critical thinking Critical thinking requires that the nurse think logically about the patient's health problems and how best to address them.

Which assessment data would indicate a potential complication associated with the skin of a patient?

Crusting Crusting is not normal and can be a sign of infection.

A couple informs the nurse that they do not believe in taking their newborn child to see a health care provider until the age of three. Which diversity consideration is the couple demonstrating?

Culture Cultural considerations occur when cultural factors influence a patient's ability or desire to seek medical assistance. The newborn's parents are a factor that may influence the desire to seek medical attention for their child.

Finds the cause of infection and antibiotic treatment

Culture and sensitivity (C&S)

A nurse is giving discharge instructions to a patient with a new diagnosis of Lyme disease. What should be included in the instructions?

Do a thorough skin check whenever you are outdoors in a wooded area. This is good advice for anyone who is going out into a wooded area. They should always complete a thorough skin check to look for ticks as soon as they are able. Lyme disease is spread through the bite of an infected tick. Correct No special isolation precautions are necessary during recovery. Lyme disease is spread through the bite of an infected tick and is not spread through contact, droplet or the air. No isolation precautions are necessary.

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? Bladder and bowel control and toileting are ADLs. Poor bowel or bladder control can indicate incontinence or declining health. How often do you take a bath or shower? Regular bathing is an ADL and is required for good hygiene. Can you bathe yourself without help? Bathing is an ADL and help should be arranged if the patient needs assistance with this.

A patient arrives at the emergency room with a puncture wound. What type of injury best describes a puncture wound?

Dog bite A dog bite best describes a puncture wound due to the nature of the injury.

A nurse is working with a student nurse who asks about orthostatic hypotension. The nurse responds that it occurs when the patient stands up and experiences a sudden change in vital signs. Which changes in vital signs are indicative of orthostatic hypotension?

Drop in systolic blood pressure of 20 mm Hg A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as orthostatic hypotension. Increase in heart rate of 20 beats/min An increase in heart rate of 20 beats/min when a patient stands is classified as orthostatic hypotension. Drop in diastolic pressure of 10 mm Hg A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

For the unconscious patient, which complication can occur if proper mouth care is not performed?

Dry mouth Dry mouth can cause a crusted tongue and crusted mucous membranes, which can lead to infection.

Which characteristic of the nursing process refers to changes over time in response to patients' individual needs?

Dynamic The dynamic characteristic of the nursing process refers to how the nursing process changes over time in response to patients' individual needs.

What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient?

Early ambulation after surgery Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity.

When caring for a malnourished patient, the nurse performs her skin assessment. Which areas of the skin should the nurse especially observe for redness and breakdown?

Elbows The bony prominences of a malnourished patient are especially important to observe when performing a skin assessment. The elbows are included in the bony prominences. Sacrum The bony prominences of a malnourished patient are especially important to observe when performing a skin assessment. The sacrum of a patient is especially important to observe during a skin assessment, because most patient lay on their backs and excess pressure is placed on the sacrum. Hips The bony prominences of a malnourished patient are especially important to observe when performing a skin assessment. The hips are included in the bony prominences. Even when patients are turned, if the patient is malnourished, a small amount of pressure can cause redness and breakdown. Heels The patient's heels are another important place to observe, especially on the malnourished patients, because the patients do usually favor lying on their backs.

What is an early sign of a systemic infection?

Elevated temperature A slightly elevated temperature is an early sign of infection and is one of the body's early defence mechanisms.

Which vital signs when altered may indicate an infection?

Elevated temperature An elevated temperature, either at the infection site or systemically, may indicate the presence of an infection. Increased pulse and respiratory rate Increased pulse and respiratory rate may indicate a serious systemic infection Elevated blood pressure Changes in blood pressure, specifially a BP that is elevated above normal may indicate the presence of an infection.

How does soap work?

Emulsifies fat and oil so that dirt and microorganisms can be mechanically removed

Measures degree of inflammation in the body

Erythrocyte sedimentation rate (ESR)

A nurse is caring for a patient at an increased risk for a systemic infection. Which blood test would indicate that inflammation is present?

Erythrocyte sedimentation rate (ESR) ESR shows that inflammation is occurring and measures the degree of inflammation in the body.

A patient on bed rest is concerned about developing constipation. What actions should the nurse take to prevent this from happening?

Increase the patient's dietary fiber and fluid intake. The patient's dietary fiber and fluid intake should be increased to prevent constipation in the immobile patient

Which step is a part of the nursing process?

Evaluation Evaluation is the fifth step in the nursing process.

A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect?

Evaluation During evaluation, the nurse reviews patient outcomes to determine whether the patient's goals and nursing diagnoses were appropriately met or addressed.

A nurse is teaching new graduates about components of the innate immune response. According to the nurse, in which organs will normal flora be found?

Eyes Normal flora may be found on the eyes. Skin Normal flora may be found on the skin. Mouth Normal flora may be found in the mouth.

What psychosocial alteration is a consequence of bed rest and manifests in the patient becoming lonely or depressed?

Feelings of isolation Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed.

A nurse is reviewing the discharge instructions for a patient with a skin infection. What should be included in the instructions?

Finish the entire course of antibiotics, even when you are feeling better. It is important to remind the patient to take the entire course of prescribed antibiotics, even when she is feeling better. This ensures that all of the infectious agents are destroyed, and minimizes the risk for drug resistance.

Which is considered a systemic infection?

Flu The flu is indicative of a systemic infection which has entered the bloodstream.

A nurse is caring for a comatose patient and is concerned that the patient may develop a urinary tract infection. Which items should be included in the nurse's assessment?

Fluid intake and output Assessment of urinary elimination should include intake and output. Concentration and odor of urine Assessment of urinary elimination should include the concentration and odor of urine. Urinary frequency Assessment of urinary elimination should the frequency of urination

Nursing observations regarding a patient's nutritional needs include which items?

Food intake Nursing observations regarding a patient's nutritional needs include food intake. Food preferences Nursing observations regarding a patient's nutritional needs include food preferences. Changes in weight Nursing observations regarding a patient's nutritional needs include changes in weight. Physical status Nursing observations regarding a patient's nutritional needs include physical status.

A nurse manager is reviewing the policies and procedures related to needle sticks on the unit floor. The nurse manager notes that, per policy, HIV should be tested when such a situation occurs. What additional testing should be added?

Hepatitis B Hepatitis B is a blood-borne infection and can be transmitted through a needle stick. It should be added to the list of infectious diseases that are tested after a needle stick Hepatitis C Hepatitis C is also a blood-borne infection and should be tested after a needle stick due to the risk of transmission.

A nurse is caring for a patient with a suspected parasitic infection. What is important for the nurse to ask about during the health history?

History of recent sexual partners Parasitic infections are typically transmitted via an infected sexual partner, by insects or domestic animals. The nurse should ask about exposure to all three potential vectors.

The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?

Hold the slide board stationary.

A student nurse is conducting a survey of health care-associated infections (HAIs) in her community. What facilities should the student nurse survey?

Hospital Hospitals are among the facilities that are at risk for transmission of health care-associated infections. All local hospitals should be sent the survey. Dialysis center A dialysis center is also included as a facility where HAIs are tracked. They should be surveyed. Ambulatory surgery facility Ambulatory surgery centers are possible facilities where HAIs can be transmitted due to the risks associated with surgery.

is mediated by circulating antibodies which coat antigens and target them for destruction.

Humoral immunity Humoral immunity is one type of adaptive immunity and is also known as antibody-mediated immunity. It utilizes specialized cells, known as antibodies, to respond to foreign antigens or pathogens.

Which statements are accurate regarding humoral and cellular immunity?

Humoral immunity is antibody-mediated. Humoral immunity involves B lymphocytes that produce antibodies Cellular immunity is cell-mediated. Cellular immunity involves T lymphocytes that defend against microorganisms the body doesn't recognize as its own.

Fever is caused by prostaglandins acting on which part of the body?

Hypothalamus Fever is caused by prostaglandins acting on the hypothalamus.

In what situation should passive range-of-motion exercises be stopped?

If resistance to movement is felt Range-of-motion exercises are stopped when resistance to movement is experienced.

Mr. Smith presents to the emergency department with an active bronchial infection. He is a 67-year-old male, with chronic obstructive pulmonary disease (COPD) for which he takes a daily course of steroids. Which factors contribute to him being a susceptible host?

Immunosuppressed The long-term use of steroids is known to suppress the immune system. The patient is therefore, immunocompromised and a higher risk for development of infection. Chronically ill Mr. Smith is chronically ill with COPD. The presence of this chronic medical condition makes him more susceptible to infection.

What happens to the musculoskeletal system when injury or disease occurs?

Impaired mobility When injury or disease occurs to the musculoskeletal system, it can lead to impaired mobility. Decreased capacity for exercise When injury or disease occurs to the musculoskeletal system, it can lead to decreased capacity for exercise.

What does paresis mean?

Impaired mobility and movement Impaired mobility and movement is paresis.

The nurse is caring for an older female patient with recent stroke. In the shift report, the nurse learns that the patient has right-sided hemiparesis. What does this mean?

Impaired movement of the right side Right-sided hemiparesis is impaired movement of the right side, and is a result of brain injury of the left side of the brain.

A patient has been diagnosed with heart failure. He asks the nurse for clarification on which part of the heart is ineffective. The nurse teaches the patient that heart failure is related to what?

Impaired ventricle Heart failure is caused by any heart condition that impairs the ventricle's ability to fill and expel blood.

Overview of Body Defenses

In healthy individuals, exposure to foreign antigens triggers one or more immune processes that help prevent infection from developing. The body's immune system may be divided into two systems: innate immunity and adaptive immunity. Innate Immune Response Innate immunity provides immediate, short-term, and non-specific defense against a foreign antigen immediately or within hours of the antigen's presence in the body. Components of the innate immune response include the inflammatory response, normal flora, and physical and chemical barriers to pathogens. Innate immunity is present in most people at birth. Adaptive Immune Response Adaptive immunity provides active, long-term defense against a foreign antigen. Adaptive immunity is acquired over a lifetime. If a pathogen gets past the innate response, it is attacked by the adaptive immune response. Adaptive immunity responses include the generation of antigen-specific antibodies and lymphocytes. Adaptive immunity also includes humoral and cellular immunity.

Overview of Movement

In summary, the musculoskeletal system is a framework for movement made up of bones, muscles, tendons, ligaments, cartilage, and joints. The nervous system controls voluntary muscular movement, posture, balance, and gait. The cardiopulmonary system works to transport and circulate oxygen, essential chemicals, nutrients, and fluids to the body. The musculoskeletal, nervous, and cardiopulmonary systems work together to enable mobility. Nurses must understand how body systems facilitate movement in order to help patients achieve or maintain their highest level of independent function.

Assessment Related to Infection

Infection has physiologic effects on the body's immune system. Whether the infection is acute, chronic, localized, or systemic, it is the nurse's responsibility to recognize the signs of infection and apply interventions to prevent progression of the infection. The nurse can assess for infection through general assessment, nutrition assessment, and risk assessment, which are performed through interviewing the patient as well observation of the patient. An assessment of vital signs that shows abnormality indicates to the nurse that infection may be present. Laboratory testing of the blood including CBC, WBC count, ESR, and C&S can assist in detecting abnormalities in a patient's body, indicating the possibility of infection. Age, gender, cultural beliefs, disability, and morphology can increase a patient's risk of infection. The nurse must take each of these factors into consideration when assessing the patient for infection or risk for infection.

Ineffective oral hygiene can lead to which mucous membrane problem

Inflammation Inflammation of the oral mucous membrane could be an indicator of such diseases and problems as diabetes, heart attack, and stroke. Halitosis Halitosis is closely related to poor hygiene, although hygiene is not the only reason a patient may have halitosis. Proper follow-up will determine the reason for halitosis. Dry mouth Dry mouth can be a result of poor oral hygiene, though this is not the only reason a person may develop dry mouth. Proper follow-up will determine the reason for dry mouth.

Gingivitis

Inflammation of the gums

The nurse is observing a patient ambulate around the room and notes the patient has an unsteady gait. What action should the nurse take next?

Initiate a fall prevention plan for the patient. An unsteady gait places the patient at risk for falling, and the nurse should initiate fall preventions measures to ensure the patient's safety.

Which type of immunity serves as the body's first line of defense and provides immediate protection against foreign antigens?

Innate immunity Innate immunity serves as the body's first line of defense and provides immediate protection against foreign antigens.

A patient eats contaminated food, but does not feel ill. The nurse explains to the patient that gastric acid in the stomach kills certain types of harmful microorganisms. What type of immunity is the patient exhibiting?

Innate immunity The gastrointestinal system has a role in the innate immune response to fight infection: the low pH of stomach acid helps destroy certain types of harmful microorganisms.

A patient complains of feeling that the room is spinning when she turns her head to the side, even though she is in a prone position. What is the suspected source of this complaint?

Inner ear fluid Inner ear fluid would cause balance disturbance when the head is moved quickly.

A nurse is caring for a patient with complaints of balance problems. What could be the source of this abnormal finding?

Inner ear infection Balance depends on the cerebellum and inner ear.

A nurse is teaching new graduates about the body's innate immune response. Which body systems should she include in her explanation?

Integumentary system The skin contains squamous epithelial cells that help to remove microorganisms and other infectious agents Gastrointestinal system The low (acidic) pH of stomach acid helps destroy certain types of harmful microorganisms. Respiratory system The respiratory system contains cilia and mucus that move or trap foreign bodies, therefore decreasing the risk for infection.

A nurse is caring for a patient with an indwelling intravenous catheter. What is the most likely portal of entry for an infection?

Integumentary tract The integumentary tract is the skin. IV lines are placed through the skin and into the veins. The portal of entry is through the skin at the IV placement site.

While caring for an immobile patient, the nurse notes the patient has a poor appetite. What action should the nurse take to encourage the patient's nutritional intake?

Interview the patient for food preferences. The nurse should interview the patient for food preferences as this information can be used to adjust the patient's diet more to the patient likes.

Which interventions might the nurse implement in order to prevent pressure ulcers?

Keeping the patient's skin clean and dry Keeping the patient's skin clean and dry prevents the buildup of infection-causing organisms. It also reduces the friction and irritation that can cause a pressure wound. Resting the patient's calves on pillows Elevating the heels off of the bed is an intervention that can help prevent ulcers.

What is the function of sebaceous glands?

Keeps the hair and skin soft. Sebaceous glands are an accessory organ of the skin that secretes an oily substance that keeps the hair and skin soft.

The nurse is caring for a patient in the emergency department. The health care provider has ordered antibiotics for a positive fluid specimen of the synovial joint. Which joint is infected?

Knee The knee is considered a synovial or movable joint.

What skin changes in older adults puts them at a higher risk for skin infections?

Loss of elasticity As people age, elasticity in the skin is lost. This makes the skin thinner and less pliable. Injury is more common, leading to infection. Decreased blood supply Vascular supply to the skin occurs in normal aging. This also can contribute to infection, as there is a reduced immune response if injury should occur. Increased dryness Increased dryness of the skin in older adults puts them at a higher risk for skin infections.

The rehabilitation nurse is caring for a patient with loss of sensation to the lower extremities. What type of injury is related to this?

Lower spinal cord trauma Paraplegia and loss of sensation are most commonly associated with lower spinal cord trauma.

The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first?

Make sure the bed brakes are locked.

Match each infectious agent to its description.

May live as normal flora on and in the skin, eyes, nose, and mouth Bacteria Cannot be killed by antibiotics Viruses Are found in air, soil, and water Fungi Are transmitted by sexual contact, insects and domestic animals Parasites

Which drug resistant bacterium is most often responsible for skin infections in the community?

Methicillin-resistant Staphylococcus aureus Methicillin-resistant Staphylococcus aureus is a bacterium that has become resistant to many antibiotics. In the community, it is responsible for many cases of skin infections. In the hospital setting, it is known to cause septicemia and pneumonia.

Which microorganisms have developed resistance in the hospital setting?

Methicillin-resistant Staphylococcus aureus (MRSA) MRSA developed drug resistance in the hospital setting, but is found in both the hospital and community. Vancomycin-resistant Staphylococcus aureus (VRSA) VRSA has developed drug resistance and is found primarily in the hospital setting. Vancomycin-resistant enterococci (VRE) Vancomycin-resistant enterococci developed drug resistance in the hospital and infections resulting from these bacteria are mostly found in that environment. Clostridium difficile Clostridium difficile also developed drug resistance in the hospital and is mostly found in this setting.

A nursing diagnosis of Altered Oral Mucous Membranes related to dental disease will yield which findings upon inspection?

Missing teeth Missing teeth can be related to dental disease or poor dental hygiene. Halitosis Halitosis is a condition resulting from dental disease or a disease of the oral mucus membranes. Dry mouth Dry mouth can be related to dental disease or altered oral mucus membrane function.

Which factors increase the risk of an individual catching an infection?

Morphology Morphology, i.e., obesity can increase risk of certain skin infections. Disability Disability can increase risk of respiratory, skin and urinary tract infections. Gender Males with enlarged prostate and females are at greater risk of urinary tract infections.

What will inadequate circulation and oxygenation impact?

Movement Lack of adequate circulation and oxygenation will impact movement. Exercise Lack of adequate circulation and oxygenation will impact exercise.

Causes of Immobility

Movement is a complex process that requires coordination between the musculoskeletal, nervous, and cardiopulmonary systems. When one or more parts of any of these systems are impaired, decreased mobility may result, which can then lead to other health complications that further decrease a person's s quality of life. Physical exercise and weight-bearing exercise can reduce the risk for bone fragility, deterioration, and loss of muscle strength

Posture and gait are controlled by which system?

Nervous The nervous system controls voluntary movement, posture, balance, and gait.

Electrical impulses from nerves to muscles are communicated by what?

Neurotransmitters Neurotransmitters communicate electrical impulses from nerves to muscles.

Which types of cells are considered to be polymorphonuclear leukocytes?

Neutrophils Neutrophils are considered to be polymorphonuclear leukocytes. Eosinophils Eosinophils are considered to be polymorphonuclear leukocytes. Basophils Basophils are considered to be polymorphonuclear leukocytes.

Which are factors that contribute to the problem of antibiotic drug resistance?

Non-completion of a prescribed course of antibiotics The organisms left untreated are more likely to mutate and develop into a resistant strain. Over-prescribing of antibiotics for nonbacterial infections Exposure to unnecessary antibiotics promotes antibiotic resistance. Using inappropriate antibiotics for the infecting microorganism Exposure to ineffective antibiotics leads to development of stronger, drug resistant strains of the bacteria.

A nurse is caring for a patient with nervous system impairment. What symptoms may be associated?

Poor balance Nervous system impairment may result in poor balance. Involuntary movement Nervous system disturbance may result in involuntary movements.

What diseases or conditions make a patient more susceptible to infection from clipping toenails too short?

Poor circulation Patients with poor circulation are especially prone to infection if toenails are clipped too short. Poor circulation can cause delayed wound healing, which contributes to infection if microbes enter the wound Diabetes Patients with diabetes are susceptible to infections in the extremities because of poor circulation and wound-healing.

Broken or missing teeth, bad breath, and red or bleeding gums are indicators of ___________________?

Poor oral hygiene Broken or missing teeth, red gums, halitosis, and open lesions may indicate altered oral health or poor oral hygiene and warrant further evaluation.

The way in which an organism escapes the reservoir of infection is referred to as which component of the chain of infection?

Portal of exit The portal of exit is how the infectious agent leaves the host and spreads to other people. Coughing, sneezing and blowing one's nose is an example.

A nurse is caring for a patient with a suspected hospital acquired infection. What is the first thing the nurse should do?

Prepare to draw blood cultures as ordered. Antibiotics should be administered after the blood culture has been drawn and resulted. This information will inform the provider which microorganism is responsible for the infection and which antibiotic to prescribe.

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.

The nurse is caring for an immobile patient who refuses to turn on his side and lays on his back most of the time. Due to the patient's position, the nurse is most concern that this behavior will contribute to the patient's development of what complication?

Pressure ulcer A patient who lays most of the time on his or her back is at risk for developing pressure ulcers, due to pressure on the bony prominences.

Tissue ischemia related to immobility can lead to the development of what problem?

Pressure ulcers Tissue ischemia related to immobility can lead to the development of pressure ulcers.

What is the function of mucous membranes?

Protects the nasal, oral, vaginal, urethral, and anal passages and cavities of the body. Mucus membranes protect the nasal, oral, vaginal, urethral, and anal passages and cavities of the body.

What is an example of a living substance that functions as an antigen?

Protein molecules on the surface of pathogens Antigens include protein molecules on the surface of pathogens and non-living substances such as toxins, chemicals, drugs, and particles

Antigens are typically composed of what type of substance?

Proteins Antigens are typically composed of proteins

The nurse is assessing the oral cavity. The nurse observes that the patient's mucous membranes are very dry. Which of these should the nurse implement?

Provide mouth care every two hours and prn. The scenario does not say if the patient can perform his/her own mouth care, so providing mouth care every two hours and prn may be indicated to moisten the oral cavity and mucous membranes. Provide the patient with liquids to drink. The scenario does not provide details whether the patient can eat and drink, but providing liquids may moisten the oral cavity and mucous membranes. Provide a non-alcohol mouth rinse to the patient. Providing a non-alcohol mouth rinse to the patient will help provide moisture to the mucous membranes and oral cavity.

While performing an assessment, the nurse notes that a patient has developed redness, warmth, and swelling in the right lower leg. What complication does this place the patient risk for?

Pulmonary embolism Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism.

The nurse is caring for a young adult male in the emergency department. The patient was involved in a motorcycle crash and is now unable to move any of his extremities. What is the expected documentation of this condition?

Quadriplegia Quadriplegia is an inability to move all four extremities

After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next?

Raise the side rails on the stretcher.

A patient arrives to urgent care with an excoriation on the torso. How would the nurse note the results of the wound assessment?

Red and scaly lesions An excoriation is, by definition, a red and scaly lesion.

Which physical trait might a nurse find when treating a patient with gingivitis?

Red, swollen gums Gingivitis is characterized by red, swollen gums Yellow teeth While yellow teeth are not directly associated with gingivitis, it may be an indicator of poor oral health, which can lead to gingivitis. Bad breath Bad breath may be related to gingivitis in that both are a result from poor oral hygiene. Cracked teeth Cracked teeth are a threat for future infection of the gums, and can lead to gingivitis.

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 Redness is a sign of inflammation, which can result from an infection. Swelling Swelling is a sign of inflammation, which can result from an infection. Drainage Drainage from a wound or injury is a sign of infection.

In relation to hygiene, why is it a good practice to clean a patient's mouth?

Reduces bacteria after eating Oral care prevents bacteria from entering the body through the gingivae or oral mucosa Protects the teeth Oral care cleanses bacteria from the mouth, which protects the teeth and gingivae from bacteria that may have entered the body. Reduces bacteria after sleeping Oral care cleanses bacteria from the mouth, teeth and gingivae. It also protects the mouth from bacterial growth that has occurred during sleep. Cleans the mucous membranes Oral care cleanses bacteria from the mouth and mucus membranes, protecting teeth and preventing bacteria from entering the body through the gingivae or oral mucosa.

Voluntary movement

Regulated by the cerebral cortex

Normal flora, a group of non-disease causing microorganisms, can be found in various body systems including____________.

Respiratory Normal flora can be found in the respiratory system. Gastrointestinal Normal flora can be found in the gastrointestinal system. Integumentary Normal flora can be found in the integumentary system. Urinary Normal flora can be found in the urinary system.

The nurse is caring for a patient who has suffered multiple fractures after a motor vehicle accident. What assessment finding would be most critical?

Respiratory distress Respiratory distress following multiple fractures would be the most critical finding, particularly if there are rib fractures, as the ribs protect vital organs.

Which body system is equipped with proteins that have antimicrobial properties and promote phagocytosis?

Respiratory system The respiratory system is equipped with proteins that have antimicrobial properties and promote phagocytosis.

What body system contains cilia and mucus that move or trap foreign bodies and decrease the risk for infection?

Respiratory system The respiratory system contains cilia and mucus that move or trap foreign bodies and decrease the risk for infection.

Monitoring the patient for psychosocial alterations related to immobility includes observing for which changes?

Rest patterns Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in rest patterns. Mood Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in mood. Behavior Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes behavior. Sleep patterns Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in sleep patterns.

A nurse is caring for a young woman who was recently diagnosed with gonorrhea. What is an appropriate action by the nurse?

Return to the office for a repeat culture to ensure clearance of the infection. The patient should be advised to have a repeat culture to ensure that the antibiotic treated the infection completely.

A nurse is caring for a patient with a severe infection whose blood pressure is 87/42. What does the nurse suspect?

Septicemia Septicemia is an infection of the blood that can be life-threatening. A decreased blood pressure is a late sign of infection, indicating septicemia and sometimes shock.

The nurse is caring for a patient at risk for developing an infection and when taking vital signs, notices a severe drop in blood pressure. What does the nurse suspect?

Septicemia and shock A decrease in blood pressure in a patient at risk for a systemic infection is an indication of septicemia and shock.

What is the first line of defense against microorganisms?

Skin The skin is the body's first line of defense against microorganisms, protecting its underlying structures from external elements.

Which of these is a barrier impermeable to most infectious microorganisms?

Skin The skin is a barrier that is impermeable to most infectious microorganisms

The nurse is preparing discharge instructions to a newly paralyzed young man about high-risk conditions that can occur as a result of immobility. Which of these conditions should the nurse include in her teaching?

Skin infections Long-term immobility is a significant risk factor for skin breakdown and skin infections. If turning and position changes do not occur frequently (at least every 2 hours), the patient will suffer from pressure ulcers and infection quickly. Urinary tract infections Urinary tract infections (UTIs) occur in patients who are paralyzed because they are unable to sense the need to empty their bladder. In addition, the use of indwelling urinary catheters to help empty the bladder will significantly increase the risk of developing UTIs. Respiratory infections Respiratory infections are more common in the immobile patient because their lungs build up respiratory secretions more frequently (walking and regular movement helps to clear those secretions). They may also have decreased sensation alerting them to clear those secretions by coughing.

Which portion of the musculoskeletal system contains both flat bones and immobile joints?

Skull The skull contains both flat bones and fibrous or immobile joints.

A nurse has been caring for a patient on bed rest for the last several days. The patient has been calm and cooperative. Today, however, the patient is angry and upset about being woken up every night. The nurse suspects the patient may be developing which problem?

Sleep pattern disturbance The patient is probably developing sleep pattern disturbance, due to disruptions to the patient's sleep for care and treatments at night.

The nurse is caring for an older adult patient with very fragile skin. The patient has plastic tape on the skin around the IV site. What is the best way to remove the tape without damaging the patient's skin?

Slowly pull the tape off while pushing the skin away from the tape. Slowly pulling the tape off the patient, while pushing the patient's skin away from the tape is the best method to help prevent damaging the skin.

When discharging a patient with diabetes mellitus, it is important to include which items to buy when educating about the importance of skin integrity?

Small mirror A small mirror is most helpful to check the areas of the foot not normally within the line of sight.

Match each component of the chain of infection to the example that represents it.

Source Inanimate object Infectious agent Parasite Portal of exit Blood Mode of transmission Droplet Susceptible host Chronically ill adult

What cells contained in the skin help remove microorganisms and other infectious agents?

Squamous epithelial cells Squamous cells help remove microorganisms and other infectious agents.

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 Gathering subjective data about the effects of hygienic practices helps the nurse decide on a specific care plan for the patient. This type of information can be helpful for the nurse who is trying to determine whether a patient is able to care for him or herself. Correct Objective data Gathering objective data about the effects of hygienic practices helps the nurse decide on a specific care plan for the patient. Noticing bad breath, skin infections, or poor dental hygiene are all examples of objective data. Correct Patient's answers The patient's answers during the health interview can be useful for a nurse assessing a patient's ability to perform basic ADLs.

Overview of the Integumentary System and Mucous Membranes

Summary The integumentary system is composed of the skin and its accessory organs, the sweat glands, hair, the sebaceous glands and nails. Skin is the body's outer-most protective layer. Proper hygiene of the integumentary system is important for the health of a patient. The mucous membrane, continuous with the skin, lines the oral cavity. Teeth and gums must be kept clean and healthy to maintain proper chewing, ingestion, and digestion of food. Like the skin, the mucous membranes also provide protection from outside elements.

Which of these could be the site of a localized infection?

Surgical wound A surgical wound could be a site of localized infection along with an abscess and a pressure ulcer. Abscess An abscess could be a site of localized infection along with a surgical wound and pressure ulcer. Pressure ulcer A pressure ulcer could be a site of localized infection along with a surgical wound and an abscess Oral lesion An oral lesion could be a site of localized infection along with a surgical wound, a pressure ulcer, and an abscess.

What decreases the likelihood of infection because its low pH inhibits bacterial growth?

Sweat Sweat decreases the likelihood of infection because its low pH inhibits bacterial growth

Which symptoms are most often triggered by the inflammatory response?

Swelling The inflammatory response produces swelling at the affected site. Warmth The inflammatory response often produces warmth at the affected site. Pain Inflammation does cause pain at the site of injury.

A patient arrives in the emergency department complaining of lethargy, with signs of anorexia, an increased heart rate, and fever. What type of infection do these symptoms indicate?

Systemic infection The symptoms listed are indicative of a systemic infection that has entered the bloodstream.

Which type of cell plays a dominant role in cellular immunity?

T lymphocytes Cellular immunity is characterized by the dominant role of T-cell lymphocytes to acquire immunity.

Which cell is a form of lymphocytes?

T-cells T-cells are lymphocytes which read an antigen signal and convey messages to other immune cells.

The nurse notices an older adult patient has food debris in his teeth. When the nurse mentions it, the patient states, "I clean my teeth every day." What should the nurse assess next?

Technique The patient's technique could be relevant because it could directly affect the outcome of the brushing.

Which structure starts the process of mechanical digestion?

Teeth Teeth are hard, bony structures found in the mouth. They begin the process of mechanical digestion by breaking up the food while chewing.

Spread of Infection

The chain of infection includes an infectious host, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host. Pathogens are the disease-producing microorganisms that cause infection and can include bacteria, viruses, fungi, and parasites. When these microorganisms develop resistance to medications that had been previously successful at treating the infection, this is called drug resistance. This can be seen in both community- and hospital-acquired infections. HAIs are infections acquired in a health care facility. Exposure and disease development can be decreased with the appropriate precautions and barriers.

What should the nurse inspect when evaluating the oral cavity?

The color of the oral mucosa The color and quality of the oral mucosa can indicate the presence of other health conditions, such as oxygenation and hydration status. The nurse should note color, condition, and the presence or absence of moisture. Open sores in the mouth Open sores should be noted and documented, if present in the patient's mouth. This can indicate many other health conditions and may warrant further assessment or investigation. Dryness of the mouth or oral cavity Dryness of the mouth or oral cavity can indicate the patient's hydration status. Chronic dry mouth may indicate dehydration, or might be a side effect of a medication that the patient is taking. Broken or missing teeth Broken or missing teeth should be documented, and the patient referred to the dentist for follow-up care.

Why is it important for the nurse to participate in providing a patient's personal care?

To spend time with the patient Spending time with the patient helps form a good nurse-patient relationship; this can be accomplished through providing a patient's personal care. To perform a more comprehensive assessment Performing a more comprehensive assessment allows the nurse to directly observe the patient's entire body, which the patient may otherwise be reluctant to allow viewing. To help gain the trust of the patient Spending time helping the patient with personal care helps the patient-nurse relationship, and helps build the trust of the patient.

Assessment Related to Hygiene and Personal Care

The nurse must evaluate the patient's ability to perform activities of daily living (bathing, eating, and dressing) because these are important aspects of assessment of hygiene and self-care. The nurse gathers objective and subjective information used as part of the individualized plan of care as well as for patient discharge planning. The nurse ensures that patient education and discharge planning enable the level of hygiene and self-care the patient requires. Assessments are performed before and after hygienic practices (such as during the bath and the assessment of proper perfusion). For example, during skin and hair assessment, the nurse can observe for signs of infection on the skin by looking for redness, swelling, or drainage. During oral assessment, broken or missing teeth, red gums, halitosis, and open lesions may all indicate altered oral health and poor oral hygiene.

Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site?

The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nursing process requires nurses to think analytically, using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. Calling a provider indicates the nurse is critically thinking about interventions for the patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nursing process requires nurses to think analytically using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse is assessing to see if there is new data that necessitates modification of the existing plan of care. The nurse assesses the surgical site to determine the cause of the increased pain. In addition to assessing vital signs and pain level, the nurse should assess the surgical site to determine if there are new signs of poor wound healing or infection. The root cause of the pain should be considered when planning further interventions.

In which situation would it be appropriate for the nurse to use an antiseptic hand rub to perform hand hygiene?

The nurse's hands are not visibly soiled.

Overview of the Nursing Process

The nursing process is a way of thinking critically when developing and implementing an individualized care plan for a patient. The concept of the nursing process was pioneered by early nurse theorists such as Lydia Hall. The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Critical thinking and using the nursing process helps nurses to collect essential data, clearly express the needs of patients, and communicate those needs to the health care team. Realistic goals can then be set and interventions can be customized. The nursing process is dynamic, collaborative, outcome-oriented, organized, analytical, and adaptable. Using the nursing process helps ensure that patients receive effective and safe care in any health care setting.

A patient in the telemetry unit is preparing for discharge after suffering an acute myocardial infarction. What does the nurse tell the patient about his expected level of activity after discharge?

The patient should expect that previous levels of activity will take time to rebuild. After an acute myocardial event, the patient cannot expect to resume all previous levels of activity because movement and exercise may be compromised.

Match the dates to the correct historical development in nursing.

The term "nursing process" was first used by Lydia Hall. 1955 The nursing process was first used to define steps used in patient care. 1960s ANA identified 5 steps of the nursing process in its Standards of Practice. 1973 Outcome identification was added to the nursing process by the ANA. 1991

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.

Skin that appears darkened or reddened is indicative of what problem?

Tissue ischemia Skin that appears darkened or reddened is indicative of tissue ischemia.

What is the main goal of focused questioning of the patient?

To detect alterations due to immobility The goal of focused questioning is to detect alterations due to immobility.

The nurse is discussing the guidelines for proper hand hygiene with nursing assistive personnel (NAP). Which statement made by NAP requires follow-up by the nurse?

To prevent dry skin, I avoid using soap and water.

Monitoring the patient for urinary and gastrointestinal alterations related to immobility includes which observations?

Urinary frequency Monitoring for urinary and gastrointestinal alterations related to immobility includes urinary frequency. Assess concentration, odor, and frequency. Fluid intake Monitoring for urinary and gastrointestinal alterations related to immobility includes fluid intake. Assess I&O. Food intake Monitoring for urinary and gastrointestinal alterations related to immobility includes food intake. Assess intake of dietary fiber. Bowel frequency Monitoring for urinary and gastrointestinal alterations related to immobility includes bowel frequency to avoid potential fecal impaction.

Which of these are older adults at an increased risk of developing?

Urinary tract infections Older adults are at increased risk for urinary tract infections due to incomplete emptying of the bladder and decreased sphincter control. Respiratory infections Older adults are at increased risk for respiratory infection due to decreased cough reflex. Skin infections Older adults are at a high risk of developing skin infections due to the loss of elasticity, increased dryness, thinning of the epidermis, slowing of cell replacement, and a decreased vascular supply.

Abrasion

Usually superficial with little bleeding

A nurse is caring for a patient who is suffering from an infection from contaminated food. What is an example of this type of transmission?

Vehicle Vehicle-transmitted infections are those that are spread through contaminated food and water.

What bone is considered irregular?

Vertebrae Vertebrae are considered irregular.

A nurse is teaching several nursing students about the principles of infection control. This nurse knows that they understand the material when they make which statement about the most important intervention a nurse can do to prevent infection?

Wash hands regularly. Regular hand hygiene has been shown to be the most effective method of reducing infection. All healthcare workers should wash hands before and after every patient, and as needed during care.

A patient arrives to the emergency room with a laceration. What intervention best shows that the nurse is using proper hygiene to prevent infection?

Washing hands with soap and water prior to treatment Washing hands is the most important step that the nurse can take to prevent infection. Using gloves Using gloves during treatment decreases the chance of introducing microorganisms into the wound. Using sterile pads while trying to control the bleeding Using sterile pads helps reduce the introduction of microorganisms and possible infection to the wound.

What is the best way to prevent the spread of microorganisms in nursing?

Washing the hands before and after each patient Washing the hands before and after each patient is the best way to prevent the spread of microorganisms.

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.

Which musculoskeletal conditions does immobility predispose a patient to developing?

Weakness Immobility predisposes a patient to weakness due to inactivity. Decreased muscle tone Immobility predisposes a patient to decreased muscle tone, due to inactivity. Decreased muscle mass Immobility predisposes a patient to decreased muscle mass, due to inactivity.

Which questions should the nurse ask to assess the effect of the patient's activity level on body systems?

What is the frequency of bowel movements? Asking about the frequency of bowel movements assesses the effects of the patient's activity level on the gastrointestinal system. Do you become short of breath when completing your activities of daily living? Asking if the patient becomes short of breath assesses the effect of the patient's activity level on the cardiopulmonary system. Are you experiencing any pain with movement? Asking about pain on movement assess the effect of the patient's activity level on the musculoskeletal system. What is your appetite? Asking about appetite assesses the effects of the patient's activity level on nutritional intake, which affects all body systems.

A patient is admitted with pneumonia, but does not allow the nurse to complete a skin assessment upon admission. What is the best way for the nurse to assess the patient's skin?

When bathing the patient Assessing the skin when bathing the patient is the best time to complete a skin assessment. The nurse is able to view the entire body. When assisting the patient with a shower Assessing the skin when assisting the patient with a shower is a good time to view the entire body.

While talking about nutrition with a patient who has been on bed rest for several days, the patient states, "I am just not hungry. I don't understand it. I am always hungry." What is the nurse's best response to this statement?

You have been immobile for several days, which can decrease your basal metabolic rate and appetite." Decreased activity decreases the body's basal metabolic rate (BMR) and appetite.