Principles Exam 2

3. The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply. 1) Disorientation 2) Restlessness 3) Hallucinations 4) Depression

ANS: 1, 2 The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased ability to perform tasks, anxiety, muscle tension, and muscle tension. Sensory deprivation causes irritability, confusion, depression, heart palpitations, hallucinations, and delusions.

2. Which of the following is/are a benefit of bathing? Choose all that apply. 1) Constricts blood vessels 2) Increases depth of respirations 3) Gives opportunity for assessments 4) Reduces sensory input

ANS: 2, 3 Bathing presents an opportunity to perform a variety of assessments. Bathing also dilates blood vessels near the skins surface, increasing circulation. Moreover, bathing stimulates the depth of respirations and provides sensory input.

23. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1) Alginate dressing 2) Dry gauze dressing 3) Hydrogel 4) Hydrocolloid dressing

ANS: 1 Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

28. When applying heat or cold therapy to a wound, what should the nurse do? 1) Leave the therapy on each area no longer than 15 minutes. 2) Leave the therapy on each area no longer than 30 minutes. 3) When using heat, ensure the temperature is at least 135F (57.2C) before applying it. 4) When using cold, ensure the temperature is less than 32F (0C) before applying it.

ANS: 1 Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures colder or warmer than those recommended can damage tissue.

21. Which item is best for providing mouth care for an unconscious patient? 1) Foam swabs 2) Lemon-glycerin swabs 3) Hydrogen peroxide 4) Cotton-tipped applicator soaked in mouthwash

ANS: 1 Commercially packaged applicators or foam swabs are typically used to provide mouth care. Lemon-glycerin swabs are not recommended because they are drying to the oral mucosa. Hydrogen peroxide should be avoided because it is irritating to oral mucosa and may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by conscious patients as part of their routine mouth care. However, cotton-tipped applicators should not be soaked in it to perform mouth care.

18. While assessing a patient, the nurse notes that the patients nails are excessively brittle. What does this finding suggest? 1) Inadequate dietary intake 2) Normal aging process 3) Fungal infection 4) Excessive use of silver salts

ANS: 1 Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish gray discoloration of the nail plate signals excessive intake of silver salts.

9. Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incisional site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue

ANS: 1 Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. A hematoma is a collection of blood that forms under the skin. It is usually tender or painful to the touch and is usually swollen. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. It is beefy red in appearance but would not be warm or tender to the touch.

7. What is the bodys first line of defense against bacteria? 1) Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response

ANS: 1 Intact skin is the bodys first line of defense against bacteria. Once bacteria enter the body, the inflammatory response, white blood cells, and lymph glands play a role in fighting against the bacteria.

9. A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration? 1) The portion of your eye called the macula, which is responsible for central vision, is damaged. 2) Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time. 3) The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens. 4) Theres an irregular curvature of your cornea, causing your blurred vision.

ANS: 1 Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

21. A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed in order to plan interventions for that symptom? 1) Asking the patient if foods taste different now 2) Checking the patients sense of smell 3) Having the patient stand to check for balance 4) Assessing for a history of seizures

ANS: 1 Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

18. A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload? 1) Administering albuterol (a central nervous stimulant) as needed 2) Administering a tranquilizer intravenously every 2 hours as prescribed 3) Delivering oxygen at 6 L/min via nasal cannula 4) Maintaining complete bedrest in a quiet, dimly lit room

ANS: 1 Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient to relax, thus preventing sensory overload. If the patients oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone.

16. The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1) I can contract the infection by walking barefoot in the gymnasiums showers. 2) The best way to avoid contracting the infection is to use good hand washing. 3) Wearing unventilated shoes prevents the fungus from gaining contact with my feet. 4) There is really no way to prevent its spread; its highly contagious.

ANS: 1 One can contract the infection by walking barefoot in public showers, such as those in the schools gymnasium. Good hand washing does not prevent a person from contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. Although the infection is highly contagious, the spread of infection can be prevented by wearing special footwear in the shower.

4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? 1) Partial-thickness wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound

ANS: 1 Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

6. A patient with Parkinsons disease is at risk for which complication? 1) Impaired kinesthesia 2) Macular degeneration 3) Seizures 4) Xerostomia

ANS: 1 Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons disease. Seizures and macular degeneration are not associated with Parkinsons disease.

16. Which assessment finding is considered an age-related change? 1) Presbycusis 2) Hyperopia 3) Increased sensitivity to touch 4) Increased sensitivity to taste

ANS: 1 Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

12. Pressure ulcers are directly caused by which of the following conditions at the site? 1) Compromised blood flow 2) Edema 3) Shearing forces 4) Inadequate venous return

ANS: 1 Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

17. Why is the information obtained from a swab culture of a wound limited? 1) A positive culture does not necessarily indicate infection, because chronic wounds are often colonized with bacteria. 2) A negative culture may not indicate infection, because chronic wounds are often colonized with bacteria. 3) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. 4) A swab culture result does not include bacterial sensitivity information necessary to provide treatment

ANS: 1 The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

1. The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patients care plan? Teach the patient to: 1) use an electric razor for shaving. 2) apply skin moisturizer. 3) use less soap when bathing. 4) floss teeth daily.

ANS: 1 The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

14. Which step should the nurse take first when performing otic irrigation in an adult? 1) Warm the irrigation solution to room temperature. 2) Position the patient so she is sitting with her head tilted away from the affected ear. 3) Straighten the ear canal by pulling up and back on the pinna. 4) Place the tip of the nozzle into the entrance of the ear canal.

ANS: 1 The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patients head. Then continue irrigating until the canal is clean.

10. For which patient is it most important to provide frequent perineal care? The patient: 1) with active lower gastrointestinal bleeding. 2) after an episode of diabetic ketoacidosis. 3) who has a circumcised penis. 4) with a history of acute asthma.

ANS: 1 The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.

2. Which structure within the brain is responsible for consciousness and alertness? 1) Reticular activating system 2) Cerebellum 3) Thalamus 4) Hypothalamus

ANS: 1 The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

13. Which action should the nurse take when preparing a patient for a bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from the bed. 3) Have the patient completely bathe himself to promote independence. 4) Wash the patients body without assistance from the patient.

ANS: 1 When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an assist bath.

10. Which of the following describes the difference between dehiscence and evisceration? 1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. 4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

ANS: 1 With dehiscence there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention.

7. What is the primary goal that the nurse should establish for a patient with an open wound? 1) The wound will remain free of infection throughout the healing process. 2) Client completes antibiotic treatment as ordered. 3) The wound will remain free of scar tissue at healing. 4) Client increases caloric intake throughout the healing process

ANS: 1 Wounds healing by secondary intention are more prone to infection; therefore, the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake

3. For which patient(s) should the nurse avoid using back massage? One who (select all that apply): 1) underwent heart surgery 3 days ago. 2) sustained rib fractures from a fall. 3) underwent a lumbar laminectomy. 4) sustained a leg fracture in a sledding accident.

ANS: 1, 2 Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or leg fracture.

19. A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1) Dryness of the mouth 2) Bitter taste 3) Demineralization of the tooth enamel 4) Gingival hyperplasia

ANS: 4 Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause dry mouth. Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel.

2. Which factors in a health history place a patient at risk for hearing loss? Choose all that apply. 1) Being an older adult 2) Childhood chickenpox 3) Frequent otitis media 4) Diabetes mellitus

ANS: 1, 3 Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

1. Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. 1) Buccal mucosa 2) Around the lips 3) Palms 4) Tongue

ANS: 1, 3, 4 In dark-skinned people, cyanosis can be best assessed by examining the palms of the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be used.

3. Which of the following are examples of nonselective mechanical dbridement methods? Choose all that apply. 1) Wet-to-dry dressings 2) Sharp dbridement 3) Whirlpool 4) Pulsed lavage

ANS: 1, 3, 4 Wet-to-dry dressings, sharp dbridement, and pulsed lavage are all forms of mechanical dbridement. They are nonselective forms, which means that healthy tissue as well as devitalized tissue can be removed with their use. Sharp dbridement is a selective form of dbridement. With sharp dbridement, only devitalized tissue is removed.

1. For a particular patient, it has become essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Choose all that are correct. 1) Furosemide, a diuretic 2) Digoxin, a cardiotonic 3) Famotidine, an antacid 4) Aspirin, an analgesic

ANS: 1, 4 Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin and famotidine do not place the patient at risk for auditory nerve impairment.

4. Why is an accurate description of the location of a wound important? Choose all that apply. 1) Influences the rate of healing 2) Determines the appropriate treatment choice 3) Will affect the frequency of dressing changes 4) Affects patient movement and mobility

ANS: 1, 4 Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions. Wounds that can be stabilized also heal more readily than those in areas of stress. Treatment choices and frequency of dressing changes will be dependent on the condition of the wound, not the location.

24. Of the following, which is the best choice for performing wound irrigation? 1) Water jet irrigation 2) 35-cc syringe with a 19-gauge angiocatheter 3) 5-cc syringe with a 23-gauge needle 4) Bulb syringe

ANS: 2 A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-cc syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound.

30. What is a common characteristic of aging skin? 1) Increased permeability to moisture 2) Diminished sweat gland activity 3) Reduced oxygen-free radicals 4) Overproduction of elastin

ANS: 2 Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infants skin is thinner and more permeable to moisture in the environment.

22. After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1) pediculosis. 2) alopecia. 3) dandruff. 4) hirsutism.

ANS: 2 Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women.

26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-Strips 2) Abdominal binder 3) T-binder 4) Paper tape

ANS: 2 An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples, sutures, or surgical glue.

2. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. 2) Increase the risk of ischemia. 3) Delay wound healing. 4) Predispose to hematoma formation.

ANS: 2 Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

9. A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) The epidermal layer of skin was rubbed away. 4) A lesion caused by tissue compression was present.

ANS: 2 Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

3. The nurse has been teaching a parent about stimuli to develop her infants auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred? 1) Cuddling 2) Speaking 3) Feeding 4) Soothing

ANS: 2 Exposure to voices, music, and ambient sound helps develop the infants auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

11. A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into the bathtub. 2) Wait for the patient to calm down, and then give him a towel bath. 3) Allow the patient to go without bathing for a day or two. 4) Ask another staff member to attempt the tub bath.

ANS: 2 Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patients agitation, as consistency of caregivers is important for patients with dementia.

11. A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance? 1) Furosemide, a diuretic 2) Phenytoin, an anticonvulsant 3) Glyburide, an antidiabetic 4) Heparin, an anticoagulant

ANS: 2 Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances.

1. The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating? 1) Chemoreceptors 2) Photoreceptors 3) Proprioceptors 4) Mechanoreceptors

ANS: 2 Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing. 2) Secondary intention healing. 3) Tertiary intention healing. 4) Approximation healing.

ANS: 2 Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

8. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? 1) Sanguineous 2) Serosanguineous 3) Serous 4) Purosanguineous

ANS: 2 Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged.

6. A clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1) Risk for Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity

ANS: 2 The epidermis contains melanin, a pigment that protects against the suns ultraviolet rays; therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn (actual Impaired Skin Integrity), only that a risk factor is present. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection.

23. Which of the following is a correct step in removing and cleaning a hearing aid? 1) Clean only the external surfaces, not the canal portion. 2) Clean the top part of the canal portion of the device. 3) Insert a wax loop or toothpick into the hearing aid. 4) Remove the battery before taking the hearing aid from the ear.

ANS: 2 The nurse should clean the top part of the canal portion of the hearing aid using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. Nothing should be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth. The hearing aid should be turned off before removing it from the ear, but the battery is not removed at that step of the procedure. It would not likely be possible to remove the battery while the device was still in the ear.

3. A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Total Self-care Deficit 2) Bathing/Hygiene Self-care Deficit 3) Dressing/Grooming Self-care deficit 4) Activity Intolerance

ANS: 2 The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patients inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario.

19. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? 1) Risk for Infection related to subcutaneous injuries 2) Risk for Impaired Skin Integrity related to immobility 3) Impaired Tissue Integrity related to ventilator dependency 4) Impaired Skin Integrity related to ventilator dependency

ANS: 2 This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

17. After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patients problem? 1) Disturbed Sensory Perception 2) Unilateral Neglect 3) Risk for Peripheral Vascular Dysfunction 4) Acute Confusion

ANS: 2 This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

4. Which action(s) can the nurse take to prevent sensory overload? Choose all that apply. 1) Leave the television on to block out other noises. 2) Minimize unnecessary light in the patients room. 3) Plan care to provide uninterrupted periods of sleep. 4) Speak calmly with a moderate voice volume.

ANS: 2, 3, 4 To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately.

1. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply. 1) Granulation 2) Hemostasis 3) Epithelialization 4) Inflammation

ANS: 2, 4 During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

21. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? 1) Dry gauze dressing changed twice daily 2) Nonadherent dressing with daily wound care 3) Hydrocolloid dressing changed as needed 4) Wet-to-dry dressings changed three times a day

ANS: 3 A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic dbridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical dbridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well.

20. What intervention would be most appropriate for a wound with a beefy red wound bed? 1) Mechanical dbridement 2) Autolytic dbridement 3) Dressing to keep the wound moist and clean 4) Removal of devitalized tissue and a sterile dressing

ANS: 3 A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Dbridement is not necessary in this situation because there is no devitalized tissue present.

14. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath

ANS: 3 A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patients energy.

8. While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Pallor. 2) Erythema. 3) Jaundice. 4) Cyanosis.

ANS: 3 A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver function. Pallor is pale skin without underlying pink tones in the light-skinned person. Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor peripheral circulation or decreased oxygen in the blood.

6. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? 1) The patient will need to take antibiotics until the wound is completely healed. 2) Because the patients wound was left open, the wound will likely become infected. 3) The patient will have more scar tissue formation than for a wound closed at surgery. 4) The patient should expect to remain hospitalized until complete wound healing occurs.

ANS: 3 Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

5. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

ANS: 3 Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

15. Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient? 1) Lavender 2) Roman chamomile 3) Rosemary 4) Ylang-ylang

ANS: 3 Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylang-ylang are used to promote relaxation.

7. The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? 1) Encouraging family members to visit only during the day 2) Applying wrist restraints during periods of agitation 3) Playing soft, calming music during the evening 4) Administering lorazepam (a tranquilizer)

ANS: 3 Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

31. Which client does the nurse recognize as being at greatest risk for pressure ulcers? 1) Infant with skin excoriations in the diaper region 2) Young adult with diabetes in skeletal traction 3) Middle-aged adult with quadriplegia 4) Older adult requiring use of assistive device for ambulation

ANS: 3 The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.

18. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? 1) Client will maintain intact skin throughout hospitalization. 2) Client will limit pressure to wound site throughout treatment course. 3) Wound will close with no evidence of infection within 6 weeks. 4) Wound will improve prior to discharge as evidenced by a decrease in drainage.

ANS: 3 The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

8. Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? 1) Limit oral hygiene to one time a day. 2) Teach the patient to combine foods in each bite. 3) Assess for sores or open areas in the mouth. 4) Instruct the patient to avoid salt substitutes.

ANS: 3 The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

24. The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patients artificial eye. What should the nurse do to best position the patient for this procedure? Ask the patient to: 1) Lean forward and rest the arms on the overbed table. 2) Sit back in the chair and tilt the head back. 3) Move to the bed and lie down. 4) Stand up and lean over the bed.

ANS: 3 The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall onto the bed instead of the floor. Sitting back in the chair would allow access to the eye but would not protect the artificial eye from falling to the floor. Leaning forward and resting the arms on an overbed table, as well as standing up and leaning over the bed, would not provide the nurse access to the eye to remove the prosthesis.

2. The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient. 2) Use cool water for bathing. 3) Provide care in small intervals. 4) Rub briskly when towel drying.

ANS: 3 The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

13. The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the childs ear canal? 1) Up and back 2) Straight back 3) Down and back 4) Straight upward

ANS: 3 The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward

19. A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? 1) Trigeminal 2) Glossopharyngeal 3) Olfactory 4) Vagus

ANS: 3 The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

27. A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) Transparent film dressing 2) Sheet hydrogel 3) Frequent turn schedule 4) Enzymatic dbridement

ANS: 3 The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic dbridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.

5. Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? 1) Self-Care Deficit: Dressing and Grooming 2) Impaired Adjustment 3) Risk for Injury 4) Activity Intolerance

ANS: 3 The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.

1. What is the function of the stratum corneum? 1) Provides insulation for temperature regulation 2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens 4) Continually produces new skin cells

ANS: 3 The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.

5. For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Choose all that apply. 1) Talk to the patient as you provide care. 2) Incorporate more touch in the plan of care. 3) Give frequent eye care if blink reflex is absent. 4) Keep the side rails up and bed in low position.

ANS: 3, 4 Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the side rails up. If the patients blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure.

2. What are two risk assessment tools used in the United States to evaluate a patients risk for pressure ulcers? Choose all that apply. 1) Pressure ulcer healing chart 2) PUSH tool 3) Braden scale 4) Norton scale

ANS: 3, 4 The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patients physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer.

22. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: 1) The ulcer is completely healed with minimal scarring. 2) The patient reports no pain at the site. 3) A minimal amount of drainage is noted. 4) The wound bed contains 100% granulated tissue.

ANS: 4 A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, and bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

13. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1) Stage II pressure ulcer 2) Stage III pressure ulcer 3) Stage IV pressure ulcer 4) Unstageable pressure ulcer

ANS: 4 An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

17. Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? 1) 99F (37.2C) 2) 102F (38.9C) 3) 103F (39.4C) 4) 105F (40.6C)

ANS: 4 Bath water temperature should be 105F (40.6C) to prevent chilling, burning, and excess drying of the skin.

15. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1) Draw a circle around the area of drainage on a dressing. 2) Classify drainage as less or more than the previous drainage. 3) Weigh the patient at the same time each day on the same scale. 4) Weigh dressings before they are applied and after they are removed.

ANS: 4 By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound, but it does not provide information how much fluid is draining.

10. A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? 1) Otosclerosis 2) Conduction deafness 3) Presbycusis 4) Central deafness

ANS: 4 Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

11. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program. 2) follows a diet plan of 1,200 calories per day. 3) is fitted for deep-depth diabetic footwear. 4) remains free of foot wounds.

ANS: 4 Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know his plan of care is effective when the clients feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal.

32. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply. 1) Is actively bleeding 2) Has swollen, tender insect bite 3) Has just sprained her ankle 4) Has lower back pain

ANS: 4 Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? 1) Antibiotic therapy for 2 weeks 2) Normal saline irrigation of the ulcer daily 3) Dbridement to the left heel 4) Elevation of the left heel off the bed

ANS: 4 Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patients left heel off the bed would relieve pressure to this area. PTS:1DIF:ModerateREF:p. 1231

14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? 1) Stage I pressure ulcer, healing 2) Stage II pressure ulcer, healing 3) Stage III pressure ulcer, healing 4) Stage IV pressure ulcer, healing

ANS: 4 Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? 1) Primary intention 2) Regenerative healing 3) Secondary intention 4) Tertiary intention

ANS: 4 Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.

3. What is the primary difference between acute and chronic wounds? Chronic wounds: 1) Are full-thickness wounds, but acute wounds are superficial. 2) Result from pressure, but acute wounds result from surgery. 3) Are usually infected, whereas acute wounds are contaminated. 4) Exceed the typical healing time, but acute wounds heal readily.

ANS: 4 The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

4. A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint? 1) Exophthalmos 2) Anosmia 3) Insomnia 4) Xerostomia

ANS: 4 The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is losing the sense of smell. Insomnia is inability to sleep

12. The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? 1) Cleanse only those areas likely to cause odor. 2) Provide the patient with warm water for washing his perineum. 3) Wash the patients back, buttocks, and perineum first. 4) Bathe the patient from head-to-toe, cleanest areas first.

ANS: 4 The nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm water and allow him to wash his perineum when giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of clean to dirty.

12. Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit? 1) Install blinking lights to alert an incoming phone call. 2) Have gas appliances inspected regularly to detect gas leaks. 3) Wear properly fitting shoes and socks. 4) Avoid using throw rugs on the floors.

ANS: 4 The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

4. Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care

ANS: 4 The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation. During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing. Early morning care typically consists of assisting with toileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and hair care. It may also include dressing and positioning or assisting the patient to the chair.

20. Which intervention is helpful when caring for a patient with impaired vision? 1) Suggest the patient use bright overhead lighting. 2) Advise the patient to avoid wearing sunglasses when outdoors. 3) Do not offer large-print books, as this may embarrass the patient. 4) Place the patients eyeglasses within easy reach.

ANS: 4 The nurse should place the patients eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful.

20. The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care? 1) Supine 2) Prone 3) Semi-Fowlers 4) Side-lying

ANS: 4 The nurse should position an unconscious patient in a side-lying position to provide mouth care to prevent aspiration. Supine, prone, and semi-Fowlers positions are unsafe positions for providing mouth care for the unconscious patient.

25. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: 1) Remove all of the soiled dressings before beginning wound treatment. 2) Cleanse wounds from most contaminated to least contaminated. 3) Treat wounds on the patients side first, then the front and back of the patient. 4) Irrigate wounds from least contaminated to most contaminated.

ANS: 4 To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

15. Wearing poorly fitting shoes may result in which condition? 1) Tinea pedis 2) Plantar wart 3) Excoriation 4) Ingrown toenail

ANS: 4 Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes come in contact with skin.

1. The nurse is making an occupied bed. Arrange the following steps in the order in which the nurse should perform them. A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. B. Lower the side rail on the side of the bed you are working on. C. Raise the side rail on the side of the bed you are working on. D. After placing clean linens and tucking them under the soiled linens, roll the patient over the hump and position him facing you on the near side of the bed.

ANS: B, A, D, C First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient. Position the patient laterally near the far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the hump, and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side.

2.____________________ is total separation of the layers of a wound with internal viscera protruding through the incision.

ANS: Evisceration

Exposure to moisture leads to ____________________ of the skin, which increases the likelihood of skin breakdown.

ANS: maceration By definition, maceration is the softening of a solid (e.g., the skin) by soaking it in a liquid.