ADLs and Mobility

Cheilosis

Ulceration and dry scaling of the lips with fissures at the angles of the mouth. Most often caused by vitamin B12 complex deficiencies (especially riboflavin)

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. Which of the following is the correct term for this condition?

Undermining

What should the nurse do to prepare the unconscious client for oral care? The nurse should

Use small amounts of water and oral suction device

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? (Select all that apply.)

Use whirlpool treatments, if ordered, until the ulcer is considered clean. Keep the ulcer tissue moist and the surrounding skin dry. Use a dressing that absorbs exudate but maintains a moist healing environment.

When transferring a client from the bed to a stretcher, it is important for the nurse to:

leave the friction-reducing sheet in place once the client is transferred.

A patient is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?

stimulates the vagus nerve to decrease the rate

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

5:00 PM Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which of the following statements indicates that the client understands?

?I will squeeze the chamber and apply the cap to maintain negative pressure.?

The nurse is performing pressure ulcer assessment for patients in a hospital setting. Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer?

A critical care patient

For which one of the following patients would a pneumatic compression device (PCD) be indicated?

A postoperative patient with a knee replacement who has a history of cancer

Caries

Cavities of the teeth Result for failure to remove plaque

Acne

Characterized by clogged pores (blackheads, whiteheads, pimples). Can appear on face, back, chest, neck, shoulders, upper arms, and buttocks. Treatments - Avoid squeezing or picking infected areas (can cause spreading and scar the tissue) - Gently wash face 2x day with a mild cleanser and warm (not hot) water - Use oil-free, water based moisturizers and make-up; Look for products that are "noncomedogenic" or "nonacnegenic" and use cosmetics sparingly to avoid further sebaceous duct blockage. - Keep hair off face and wash hair daily - Avoid sun/tanning booth exposure as some acne treatments increase skin sensitivity to UV-light - PTs with a lot of acne, cysts, or nodules should consider consulting a dermatologist.

The nurse caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings.

When performing a dressing change, the home care nurse notes that base of the client's leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse?

Document the findings.

A nurse is providing oral care to a patient with dentures. What action would the nurse do first?

Don gloves.

Dry Skin

Skin loses moister and may crack, peel, become irritated and inflamed. Symptoms include scaling, flaking, itching, and cracks to skin Treatments - Keep baths or showers short and/or bathe less frequently. - Use warm water, not hot to bathe - Use as little soap as possible; try mild cleansers instead - Dry skin thoroughly and gently - Use moisturizers daily - Drink plenty of water through the day - Use a humidifier if air is dry

A nurse is making an unoccupied bed for a hospitalized patient. Which actions are appropriate steps for the nurse to perform? (Select all that apply.)

First, adjust the bed to the high position and lower the side rails. Fold reusable linens on the bed in fourths and hang them over a clean chair. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. Tuck the bottom sheets securely under the head of the mattress, forming a corner according to agency policy.

According to common practice, when are the bed linens usually changed?

Following the bath

A nurse is caring for patients with alterations in mobility. Which nursing interventions are recommended for these patients? (Select all that apply.)

For orthostatic hypotension, have the patient sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the patient in correct alignment at least every 1 to 2 hours.

Alopecia

Hair loss or baldness

Tartar

Hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria. Attacks the fibers that secure teeth and eventually attacks bone tissues

In planning care for clients who need to be ambulated, the nurse knows that a gait belt should be used on which clients? (Select all that apply.)

Cooperative clients Clients who require minimal assist

A nurse is obtaining vital signs from patients using the tympanic method for measuring temperature. Which of the following guidelines should be followed when taking a tympanic temperature?

Do not take a tympanic temperature if the patient has an earache.

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is

"I will set up your bath for you. I will come back and help you with your back."

Which teaching points would the nurse use to explain the development of pressure ulcers to patients and how to prevent them? (Select all that apply.)

"Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation."

A nurse educator is teaching a patient about a healthy diet. What information would be included to reduce the risk of hypertension?

"Put away the salt shaker and eat low-salt foods."

A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply.

Bathing removes organisms from the skin, reducing infection. Bathing can stimulate circulation. Bathing can improve appearance and self-image.

You are preparing to measure a patient's rectal temperature. Which of the following supplies and equipment should you have available before beginning the procedure? Select all that apply.

An electronic thermometer with a rectal probe Disposable probe cover Water-soluble lubricating gel

The nurse takes a client's vital signs and notes a blood pressure of 88/56 mmHg with a pulse rate of 60 beats/min. Which action should the nurse take first?

Assess the client for dizziness

A client has had a left-side mastectomy. How does this affect the blood pressure assessment?

Assessment of blood pressure is impeded If the client has had a mastectomy, blood-pressure monitoring on the same side can further impede circulation, contributing to lymphedema.

Students are reviewing information about activities of daily living. They demonstrate understanding of this topic when they identify which of the following as an activity of daily living?

Bathing

A nurse is caring for a female client with diarrhea. What instruction should the nurse give the client with regard to perineal hygiene?

Clean the perineal area from the front to back

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure?

Clean the wound from the top to the bottom and center to outside. Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge in the same manner and apply ointment and dressing.

Which of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

When giving a back rub to an older patient at home, the nurse notices a stage II pressure ulcer. What nursing interventions would the nurse perform next?

Clean the wound with normal saline.

A nurse is assessing the pulse rate of a client for one full minute. Which of the following clients' pulse rates need to be assessed for one full minute? Select all that apply.

Clients with abnormally slow pulse rates Clients with irregular pulse rates Clients with fast pulse rates

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which of the following actions will she perform?

Create a calming environment with little stimuli.

You are preparing to assess a patient's oral temperature. You should plan to place the thermometer probe in which of the following areas of the patient's mouth?

Deep in the posterior sublingual pocket

A nurse is logrolling a patient who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?

Enlist the assistance of two or three other nurses to perform the procedure.

Skin Rashes

Eruptions or inflammations of the skin that may be found anywhere on the body. May be caused by skin contact with an allergen, overexposure to sun, and/or systemic causes such as reaction to a medicine Treatments - Wash area thoroughly with a mild cleansing agent and rinse well - Use a moisturizing lotion on a dry rash to prevent itching and promote healing - Use a drying agent on a wet rash - Try tepid baths to relieve inflammation and itching - Use antiseptic sprays or lotions to lessen itching, promote healing, and prevent skin breakdown - Avoid exposure to causative agent, if known - See healthcare provider if symptoms to dot respond to treatment or become worse

Which nursing actions are recommended guidelines when performing oral care? (Select all that apply.)

Ideally, brush teeth immediately after eating or drinking. If desired, use an automatic toothbrush to remove debris and plaque from teeth. If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

Three nurses are transferring a patient from a bed to a chair. Which of the following is a recommended guideline for handling patients safely during a transfer?

If patient is in pain, administer analgesics in advance.

Pediculosis

Infestation with lice

Gingivitis

Inflammation of the gingivae or gums

Stomatitis

Inflammation of the oral mucosa with numerous causes such as: Bacteria, virus, mechanical trauma, irritants, nutritional deficiencies, and systemic infection. Symptoms - heat - pain - increased saliva flow - halitosis

Glossitis

Inflammation of the tongue Can be caused by deficiencies of vitamin B12, folic acid, and iron.

Plaque

Invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel

When turning a patient in bed, what muscle groups would the nurse use to pull the patient to the opposite side of the bed?

Leg

The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds.

Which of the following statements accurately describes a recommended step when making an unoccupied bed?

Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. Fold reusable linens, such as sheets, blankets, or spread, in place on the bed in fourths and hang them over a clean chair. Snugly roll all the soiled linen inside the bottom sheet and place directly into the laundry hamper. Place the top sheet on the bed with its center fold in the center of the bed and with the hem even with the head of the mattress.

Peridontitis

Marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues and bone) Symptoms: bleeding gums; swollen red, painful gum tissues; receding gum lines with the formation of pockets between teeth and gums; Pus that appears when gums are pressed; and loose teeth.

Using the Katz Index of Independence in Activities of Daily Living, what indicators would cause the nurse to categorize the client as dependent? (Select all that apply.)

Needs partial assistance with feeding Uses the bedpan for toileting

Which of the following is one of the most important benefits of a nurse helping with bathing?

Nurse-patient relationships are facilitated.

Halitosis

Offensive breath and/or persistent bad taste in mouth May be first indication of periodontal disease Treatment by a dentist is I'mperative

When assessing an infant's axillary temperature, it will be

One degree lower than an oral temperature

While receiving report, the nurse learns that a patient has paraplegia. The nurse will plan care for this patient based upon the understanding that the patient has which of the following?

Paralysis of the legs

A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply.

Provide incontinent care every 2 hours and as needed Turn client every 2 hours while client in bed Encourage client to take fluids every 2 hours

You are preparing to perform oral care for a patient who has full dentures. Which of the following actions should you take? Select all that apply.

Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. Provide privacy while the patient removes dentures from the mouth. Use a toothbrush and paste and gently brush all surfaces.

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which of the following stages of wound healing should the nurse recognize with this client's wound?

Proliferation Phase

Which of the following are functions of the skin? Select all that apply.

Protection Temperature regulation Sensation Immunological

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

Which of the following terms indicates a potentially serious patient condition?

Pyrexia

A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia.

You are planning to bathe a patient who has thigh-high antiembolism stockings in place. Which of the following actions is correct?

Remove the antiembolism stockings during the bath.

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound?

Secondary intention

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a patient with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?

Stage III pressure ulcer

A nurse is teaching an elderly patient how to use a walker. Which of the following instructions ensures accurate use of this device? Select all that apply.

Stand between the back legs of the walker. Keep arms relaxed at the side. Line up the top of the walker with the crease on the inside of your wrist.

A pulse deficit is the difference between

The apical pulse and the radial pulse rate

A nurse is caring for a client with a decreased level of consciousness. When performing mouth care, the nurse understands the importance of what type of positioning to decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

The nurse is assessing a patient's brachial artery blood pressure. Which nursing actions are performed correctly? (Select all that apply.)

The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. The nurse notes the point on the gauge at which the first faint but clear sound appears and increases in intensity as the diastolic pressure. The nurse repeats any suspicious reading before one minute has passed since the last reading. The nurse has the patient lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. The nurse wraps the cuff around the arm smoothly and snugly and fastens it.

Which nursing interventions reflect the accurate use of heat or cold during wound care? (Select all that apply.)

The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in a cold pack with a cotton sleeve to keep it in place on an arm.

The nurse is assessing a patient's blood pressure and obtains a falsely low pressure reading. Which nursing actions might have contributed to this false reading? (Select all that apply.)

The nurse performed the assessment in a noisy environment. The nurse misplaced the bell beyond the direct area of the artery The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse.

The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair.

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as unstageable. Which of the following wound descriptions should the student nurse expect to assess?

The wound is 3 cm x 5 cm with yellow tissue covering the entire wound.

When moving a patient up in bed, the nurse asks the patient to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the patient in this position?

To prevent hyperextension of the neck

Cerumen

Wax in the external ear canals' Consists of a heavy oil and brown pigment

A nurse is teaching a patient how to walk with a cane. Which of the following is an accurate guideline for using this device?

When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane.

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when she notices the skin is which color?

White The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. Insufficient blood circulation makes the skin appear paler than in areas where circulation is adequate. When the pressure is relieved, the area will appear red and feel warm. Yellow skin is indicative of jaundice. Stage I pressure ulcer is a defined area of persistent redness in lightly pigmented skin and persistent red, blue, or purple hue in darker pigmented skin.

The nurse assesses a client who has Alzheimer's disease. Her hair is dirty; her clothing is soiled and has an odor of urine. The nurse should:

help the client with her bath, allowing her to do as much for herself as she is able.

A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?

under the patient