Chapter 18: Safety, lifting & positioning patient & Chapter 19: Assisting with hygiene, personal care, skin care, and prevention of pressure injuries

A patient who is weak from inactivity following a car accident benefits most if the nurse provides for: a. passive range-of-motion (ROM) exercises to all joints four times a day. b. active ROM exercises to arms and legs several times a day. c. active ROM exercises with weights twice a day with 20 repetitions each. d. passive ROM exercises to the point of resistance or pain and then slightly beyond.

ANS: B Active ROM is best to restore strength in a weak patient who can independently perform activities of daily living but is immobilized because of injury.

Providing oral care to a patient who has dentures includes: a. asking the patient to place his teeth directly in a covered, labeled container for overnight storage. b. removing, cleaning, and storing the dentures in a labeled container at bedtime. c. cleaning the dentures in hot water after each meal to remove debris and bacteria. d. using a toothbrush and toothpaste to clean the dentures in the patients mouth.

ANS: B Dentures should be removed and cleaned before they are stored. Hot water should never be used. Dentures may be cleaned in the patients mouth, but they need to be removed to clean the patients palate and gums, as well as the undersides of the dentures.

As the nurse is helping an 85-year-old man to stand and ambulate, he complains that he feels that he has lost all of his strength in the last several years and cannot do the things he could do when he was 80. The nurses most informative response would be: a. An increase in testosterone will build your muscle bulk back to where it was when you were younger. b. As we age our muscle cells are lost and replaced by fat, which leads to loss of strength. c. Inactivity makes our muscles lazy and they just wont do the work they used to do. d. Additional vitamins will build your strength back up in a few months.

ANS: B Fat replaces muscle cells, which leads to loss of strength and stamina.

. A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse: a. places her in low- or semi-Fowlers position only. b. uses logrolling to accomplish position changes from side to side. c. moves the top half of her body first, then the middle, and finally her legs. d. keeps her in a prone position to keep pressure off her back.

ANS: B Logrolling, or moving the patients body as one unit, is used after back surgery or trauma or when twisting or flexion must be avoided. Logrolling is accomplished using a sheet and at least two persons.

The patient most at risk for a pressure ulcer would be: a. a 46-year-old man in traction for a fractured femur, who exercised regularly before his accident and is alert and oriented. b. a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed. c. a 72-year-old man admitted for elective surgery to replace his hip joint, who was an avid bowler and gardener before his hip disease slowed him down. d. an 84-year-old man with Alzheimers disease who is pacing in the halls and who is incontinent of urine if not toileted every 2 hours.

ANS: B With risk factors of obesity, immobility, lowered mental awareness, and incontinence of stool, this patient clearly is at greatest risk of developing a pressure ulcer.

It is most important for the nurse to write specific personal care plan modifications for the patient who: a. is 76 years old, alert, oriented, and able to provide his own care. b. had a hip replacement 2 years ago and uses a cane to ambulate. c. has an artificial eye and poor vision in the other. d. prefers a tub bath to a shower, preferably before bedtime.

ANS: C Special care is necessary for the artificial eye, especially because the patient has poor vision in the remaining eye.

contractures

adaptive shortening of skeletal muscle tissue rendering muscle highly resistant to stretching prevents normal joint movement

shearing force

applied force causes downward & forward pressure on tissue beneath skin

sebaceous

gland secretes oily substance called sebum

exacerbation

increase severity of disease or any of symptoms

dermis

inner fibrous layer of skin beneath epidermis

necrosis

local death of tissue from disease/injury

pressure injuries

localized damage to skin/ underlying soft tissue usually over bony prominence/ related to medical / other device

prone position

lying face down

sebum

oily substance secreted by sebaceous glands

supine position

on back

lateral position

on side

epidermis

outer thicker layer of skin

reactive hyperemia

process which blood rushes to where decrease circulation

blanch

skin turns white/pale

the nurse reminds a patient that one of the anatomic parts of a joint that allows the joint to move freely is the fluid-filled ___________.

ANS: bursa Bursa are small fluid-filled sacs that provide a cushion at friction points and provide freely movable joints.

The primary function of a joint is to provide ______________ to the skeleton.

ANS: movement Ligaments and tendons attach to bones at the joints, which allows movement.

The patient for whom passive range-of-motion exercises would be most beneficial would be the: a. 66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CVA). b. 72-year-old patient with chronic dementia who alternately sits in his wheelchair and wanders around the unit. c. 80-year-old patient with chronic lung disease who can breathe only when he is sitting in a tripod position. d. 94-year-old patient with increasing fatigue and weight loss who needs assistance to ambulate.

ANS: A A patient with a recent CVA is unable to independently change position or move the affected side. The patient may regain use of motor functions lost, so it is very important to prevent loss of muscle strength, contractures, and pressure ulcers.

A nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage _____ pressure ulcer. a. I b. III c. IV d. II

ANS: A A stage I pressure ulcer is characterized by an area of red, deep pink, or mottled skin that does not blanch with fingertip pressure.

The nurse assisting a weak patient from a bed to the wheelchair to go to physical therapy would: a. seat the patient on the side of the bed with feet touching the floor. b. place hands under the patients elbows to assist in rising. c. lock knees as the patient is lowered to the chair. d. assist the patient to don a robe after being seated in the wheelchair.

ANS: A After locking the wheels of the wheelchair, seat the patient on the side of the bed with the feet touching the floor.

When instructing a nursing assistant about hygiene needs of a frail elderly patient, the nurse correctly educates the nursing assistant to: a. Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling. b. Put bath oil in the tub and use plenty of soap to really clean the patients skin while she is in the tub. c. Use brisk drying and an alcohol rub to close the patients pores and prevent heat loss after the bath. d. Completely dry the patients skin and apply a mild moisturizer.

ANS: A Elderly people have drier, thinner skin and less subcutaneous fat. Therefore warm, not hot, water is needed, and chilling should be avoided. The elderly should use less soap (to decrease dryness), and the use of oils in the water can be hazardous. Elderly people should be patted, not rubbed, dry and moisturizer should be applied to skin that is still damp.

A patient has a quarter-sized blackened eschar on both heels surrounded by a 1- to 2-cm indurated reddened area. The nurse is aware that these lesions are: a. pressure ulcers that cannot be accurately staged because of the eschar. b. stage I pressure ulcers because of the induration and redness. c. stage II pressure ulcers because the skin has been broken. d. stage III or IV pressure ulcers because of the eschar.

ANS: A Eschar must be removed to accurately stage an ulcer, because the nurse cannot know how deep the ulcer is.

An example of the principles of good body mechanics applied to patient care occurs when the nurse: a. keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement. b. assists another nurse in pushing a patient from one side of the bed to the other. c. bends at the waist to pick up and empty or move the urinary drainage bag attached to the lower end of the side rail. d. works at arms distance from the patient when lifting or transferring the patient.

ANS: A Fixing feet and placing one foot in front of the other and facing the direction of the movement will ease the work of moving a patient up in bed. Pulling requires less effort than pushing in this scenario. Twisting should be avoided; nurses should use leg muscles rather than back muscles to pick up objects from the floor. Work should be close to the body to reduce effort and strain.

A physician orders the nurse to place a patient in Fowlers position. The nurse should elevate the head of the patients bed _____ degrees. a. 60 to 90 b. 30 to 60 c. 15 to 30 d. 10 to 15

ANS: A Fowlers position is arranged by elevating the head of the bed 60 to 90 degrees. Semi-Fowlers position is an elevation of 30 to 60 degrees, and low-Fowlers is an elevation of 15 to 30 degrees. Unless contraindicated, the knees can be raised 10 to 15 degrees in these positions.

A nurse is instructing one of the facilitys unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, I will: a. lift using my back muscles. b. obtain help whenever possible. c. ask the patient to help if able. d. use a wide base of support.

ANS: A Guidelines for moving and lifting include obtaining help whenever possible; asking the patient to help if able; using thigh, arm, or leg muscles rather than back muscles; and using a wide base of support.

A patient who has a dry, itchy dermatitis will most likely benefit from: a. an oatmeal or starch therapeutic bath with tepid water. b. having his skin patted with alcohol to decrease the itching. c. a very warm whirlpool bath for 20 to 30 minutes. d. avoiding any skin contact with water in the affected areas.

ANS: A Oatmeal or starch baths are used to soothe dermatitis. Very hot water, soaps, perfumes, and alcohol rubs are contraindicated. The skin must be kept clean, even if there is dermatitis present, so although bathing may be decreased or modified, it is not eliminated.

A usual routine for providing nail care to a patient includes: a. soaking the nails in warm soapy water to soften before cleaning under the nail edge with an orangewood stick. b. gently cleaning under the nails with a metal file to remove dirt and dead skin and then soaking hands or feet afterward. c. cutting toenails with rounded edges to prevent scratching or ingrown nails. d. cutting toenails and fingernails every 2 or 3 days to keep them short and clean.

ANS: A Soaking nails softens them and makes it easier to remove dirt or to cut them. A metal file should not be used under the nails.

A nurse is preparing to give a complete bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse: a. washes each eye with a fresh area of the washcloth before washing the rest of the patients face. b. wears protective gloves throughout the entire procedure. c. begins with a back wash and rub to assess for pressure areas over the sacrum. d. changes the water after washing the patients face, and again after washing his back.

ANS: A The eyes should be washed without soap and before the water is soiled by face washing. Separate areas of the washcloth prevent the transfer of organisms from one eye to the other.

A nurse is ambulating an unsteady patient from the bed to a chair in the patients home. To do so safely, the nurse applies a gait belt and: a. slides his hand from the bottom under the gait belt at the middle of the patients back. b. grasps the gait belt from the top at the middle of the patients back, pulling it tight against the patients abdomen. c. has one person on each side grasp the belt from the top. d. secures a regular mans belt snugly around the patients waist to use if the patient starts to fall.

ANS: A The nurse puts his hand from the bottom at the rear, so he can pull up if the patient starts to fall and not lose the grip on the gait belt. The gait belt should be tight enough to secure the patient, but loose enough for the passage of the nurses hand.

The culturally sensitive nurse caring for a Muslim woman who has noticeable body odor as well as abundant underarm hair should: a. use soap and water under the arms. b. apply a cream type deodorant. c. shave the underarms. d. cut hair close to the armpit with scissors.

ANS: A Washing the area with soap and water will reduce odor. Several cultures do not consider the use of deodorant or shaving underarms essential. These personal preferences should be respected.

. Complications from incorrect alignment and positioning include which of the following? (Select all that apply.) a. Pressure ulcers b. Osteoporosis c. Contractures d. Increased blood pressure e. Fluid in the lungs f. Elevated temperature

ANS: A, C, E Constant pressure on the skin, especially on bony prominences, interferes with circulation, causing pressure ulcers. Contractures occur when joints are not positioned frequently, and fluid can accumulate in the lungs with infrequent positioning. Osteoporosis, increased blood pressure, and elevated temperature are not results of improper alignment or positioning.

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? (Select all that apply.) a. Summon at least one other person to assist. b. Obtain a mechanical lift. c. Perform the move by himself, because it should not be too difficult. d. Obtain a lift sheet. e. Put the bed in semi-Fowlers position. f. Place the patient flat on her back.

ANS: A, D, F The patients increased weight and inability to assist requires at least two people to move her up in bed. A lift sheet enables the patient to be moved. Placing the patient on her back decreases gravitational pull, making the move easier. A mechanical lift is used to transfer a patient, not to move her up in bed.

A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures? a. A trochanter roll to keep her legs from turning outward b. A rolled washcloth in the palm of her left hand or a hand splint c. A protective vest to keep her sitting upright in the chair d. A trapeze to permit her to change her position in bed more easily

ANS: B A hand splint or rolled cloth in the palm of her hand (along with range-of-motion exercises) will help prevent flexion contractures of her hand. A trochanter roll prevents outward rotation, not flexion.

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to: a. leave the contacts in place for up to a month. b. use a lens suction cup to remove the lens. c. request an ophthalmologist (eye specialist) to come in to remove the lenses. d. irrigate the eye with saline until the lens floats out.

ANS: B A lens suction cup is usually available in health care facilities to remove contact lenses.

A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to: a. use a mechanical lift to transfer her from the bed to a chair. b. assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt. c. have another staff member help lift her out of bed to the chair on the count of three. d. place a chair close to the bed and use a roller board to slide her into it.

ANS: B A patient who can stand can safely be assisted to pivot and transfer with the use of a transfer belt. This benefits the patient (active exercise) and is safe for both the nurse and the patient.

To place a patient in the Sims or lateral-lying position, the nurse would initially: a. raise the head of the bed to a 45- or 60-degree angle. b. raise the bed to a waist-high working level. c. bring the patient to the edge of the bed so that she will be centered when turned on her side. d. place a pillow behind the patients back to support her and prevent her from rolling onto her back.

ANS: B A waist-high bed height is a comfortable and safe working height for the nurse and also prevents staff back injuries. The head is not raised in a side-lying position; it is in a Fowlers or semi-Fowlers position.

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak? a. Perform a full bed bath, brush and floss his teeth, and give him a good back massage. b. Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary. c. Set up a washbasin and supplies, tell the patient to wash what he can, and provide privacy for the patient to do what he can. d. Teach a family member to give a full bath so that the family member will be able to care for the patient at home.

ANS: B Patients should be encouraged to do as much of their hygiene as possible (and allowed) in order to increase their sense of independence.

The nurse assessing for a pressure ulcer in a patient with darkly pigmented skin should: a. examine the area under full florescent light. b. look for a purple hue under natural light. c. reassess areas that appear lighter under a halogen light. d. identify areas of a green hue under a halogen light.

ANS: B Patients with darkly pigmented skin will show a purple coloration under natural light in the beginning stages of a pressure ulcer.

To perform oral care for an unconscious patient, the nurse takes which action first? a. Position the patient in an upright sitting position with the bed at a comfortable working height for the nurse. b. Raise the bed to a comfortable working height and position the patient in a flat side-lying position. c. Move the patient to the far edge of the bed with the head slightly elevated. d. Lower the bed, lower both side rails, and turn the patients head to one side.

ANS: B The bed should be at a comfortable working level for the nurse. The patient should be in a flat side-lying position to promote fluids draining from the mouth rather than running down the back of the throat and possibly resulting in aspiration.

The nurse instructs the patient that any injury to the skin initially puts the patient at risk for: a. scar formation at the injury site resulting from the healing process. b. infection with bacteria or viruses that may affect the person systemically. c. loss of sensation caused by damage to the nerves in the area. d. loss of body fluids and an upset in the fluid and electrolyte balance.

ANS: B The skin (and intact mucous membrane) is the first line of defense against invasion by pathogens, and any cut or abrasion can be an entry site. Scar formation, nerve damage, and fluid/electrolyte disturbance are likely only when there is a large or deep wound.

The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when: a. a lifting sheet is used to move the patient to a stretcher. b. the patient is pulled up in bed without being lifted. c. the patient is seated in a wheelchair without a pressure cushion. d. the patient is left in the supine position.

ANS: B When a patient is pulled up in bed without being lifted up first, shearing force is applied on the bony prominences and tissues of the back, which predisposes the patient to a pressure ulcer.

A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should: a. allow the patient to dangle for 10 to 15 minutes and then transfer her to a nearby chair. b. perform passive range-of-motion exercises on the patients arms and legs while she is dangling to improve circulation. c. assess the patients response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding. d. dangle the patient only momentarily and then assist her to ambulate as far as she is able.

ANS: C A patient who has been immobilized for any length of time may feel dizzy or experience a drop in blood pressure when sitting or standing for the first time. Therefore the nurse must assess the patient carefully to determine whether transfer to a chair, ambulation, or return to bed is indicated.

While the nurse is assisting a patient to ambulate, the patient suddenly says, Im dizzy. I cant stand up. As the patient begins to fall, the nurse should: a. tell the patient, Look up, take some deep breaths, and stand up straight. You can do it. b. call for another nurse or aide to get a wheelchair to return the patient to her room via wheelchair. c. step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor. d. look for the nearest chair and assist the patient to it.

ANS: C A patient who is threatening to fall needs to be lowered to the floor to avoid injury from a fall by allowing the patient to gently slide down the nurses leg to the floor.

Because the elderly patient lies curled up in a side-lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the: a. sacrum. b. heels. c. ilium. d. scapula.

ANS: C A patient who lies in a constant side-lying position puts pressure on the bony prominence of the ilium. The sacrum, heels, and scapula are at risk in a patient who lies on his or her back.

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have: a. mottled skin and induration. b. full-thickness skin loss and a deep crater. c. partial thickness skin loss with the appearance of a blister. d. a deep pink area of unblanchable skin.

ANS: C A stage II pressure ulcer is characterized by an area of partial-thickness skin loss involving the epidermis and/or dermis. It may look like an abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer.

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to: a. remove secretions that might block respiratory passages. b. remove emesis if the patient should vomit. c. prevent fluids from collecting in the patients mouth and being aspirated. d. stimulate the patients gums and mucous membrane.

ANS: C An unconscious patient may not have a gag or swallowing reflex, and thus fluids introduced during mouth care need to be suctioned out (and the patient is positioned to facilitate drainage with the head lowered and turned to the side).

The nurse caring for a patient who is not taking any food or fluids by mouth because he is unconscious is aware that the patient: a. does not need mouth care as frequently as the patient who is eating and drinking. b. should have complete mouth care once a day when the nurse assesses the condition of his skin and mucous membranes. c. needs to have his mouth swabbed to moisten and remove secretions every 4 hours. d. should have his lips lubricated and his teeth brushed with mouthwash once a shift.

ANS: C An unconscious patient needs mouth care about every 4 hours to prevent drying of secretions, halitosis, and possible blocking of the respiratory passage with accumulated dried secretions.

When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to: a. call his physician about the amount of exertion in physical therapy. b. suggest the patient walk slowly in the hall to cool down. c. offer additional fluids to replace those lost through normal cooling. d. place a light cover over the patient to prevent his chilling.

ANS: C Diaphoresis (sweating) is the bodys normal response to rid itself of heat. Drinking fluids to replace those lost prevents dehydration.

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the: a. patient will shower daily on an independent basis by the end of 1 month. b. nurse will give a tub bath or full bed bath daily. c. patient will shower or tub bathe with assistance twice a week. d. patient will tub bathe or shower with assistance daily.

ANS: C Elderly people have decreased sweat and sebaceous gland activity and do not need a full bath or shower daily. Their skin is thinner and it becomes drier and itchy with overly frequent bathing. Because of the patients unsteadiness, it is not safe to have him shower alone.

The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPNs most accurate information relative to moving patients is: a. Most of your assigned patients are able to move about a little. Dont wake them to change their positions in bed if they are sleeping. b. When you get Mrs. S up to the toilet, be sure to keep your feet together and your knees locked, or she will pull you over. c. Get one other aide to help and use the mechanical lift when you get Mr. A out of bed in the morning. He is heavy and doesnt assist at all. d. Use your back muscles to liftthat will strengthen them and make it easier for you to lift or move heavy patients.

ANS: C Getting adequate assistance and using mechanical assistance are important to reduce injury to staff and patients. It also increases the comfort of the move for the patient.

A nurse admitting a 76-year-old patient to the unit carefully documents the appearance of a stage III pressure ulcer and informs the charge nurse because: a. the presence of an ulcer suggests previous lack of care. b. the charge nurse will need to report the presence of the ulcer. c. Medicare will reimburse the facility if the ulcer advances. d. documentation of a stage III ulcer on admission is part of good assessment.

ANS: C Medicare will reimburse the facility at a higher rate if stages III and IV ulcers are documented within 2 days of admission.

When the post-stroke patient complains to the nurse, I dont see why you are wasting your time doing the passive range-of-motion exercises on my legs, the nurses most informative response would be based on the knowledge that the exercises: a. guarantee the prevention of pressure ulcers. b. are part of the basic care given to all patients. c. prevent contractures of the hips. d. maintain the muscle mass of the limb prior to the stroke.

ANS: C Passive range-of-motion (ROM) exercises, although not part of care given to all patients, does prevent contractures in persons who are bedfast. ROM does not guarantee the prevention of pressure ulcers but helps in the improved circulation of the limbs.

. The nurse caring for a patient with a nursing diagnosis of Injury, risk for, related to right-sided weakness as evidenced by unsteady gait, would accommodate the patient by: a. keeping the right arm in a sling to prevent injury. b. keeping bed rails up to prevent the patient from attempting to get up unassisted. c. placing the wheelchair on the left side of the patient before transfer. d. allowing unassisted ambulation with the support of a walker.

ANS: C Placing the wheelchair on the patients stronger side aids in transfer.

A 20-year-old male patient is admitted after an auto accident. He has blood and dirt matted in his hair. The nurse should: a. blot the tangled, bloodied hair and then provide a bed shampoo to remove the remaining dirt and debris. b. comb the tangles out with a fine-toothed comb, starting at the scalp and working down to the ends of the strands. c. remove tangles by using alcohol or water on small sections of hair, holding the hair between the scalp and the area the nurse is brushing or combing. d. shampoo the hair as well as possible and leave the tangles alone.

ANS: C Removing tangles in small sections is more comfortable for the patient. Trying to shampoo before removing some of the tangles makes the situation worse.

A patient with insulin-dependent diabetes has a below-the-knee amputation on the right leg. What modification of his personal care is noted as most important? a. Perineal care should be performed at least twice a day to prevent urinary tract infections. b. A safety razor should not be used for shaving; an electric razor should be used. c. The patient should be assisted to the shower, where he can use a shower chair. d. The patients left foot should be soaked and gently dried, but his toenails should not be cut.

ANS: D A diabetic with a below-the-knee amputation is likely to have circulatory problems in the remaining foot. Therefore, good foot care is essential, but toenail cutting should be performed by a podiatrist.

When the nurse is assisting a male patient to shave his face, it is most important for her to: a. practice on a male friend or relative before trying it on a patient. b. have the patient shave first before any other hygiene measures are performed. c. be sure the patient knows to draw the razor in the direction the hair grows. d. check whether a safety razor can be used or whether it is contraindicated.

ANS: D A patient who is on anticoagulants or who has a bleeding tendency should use an electric razor.

The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is: a. carpal tunnel syndrome from use of computer keyboards in nursing documentation. b. shoulder and elbow injuries from moving patients. c. knee injuries from standing for long periods. d. back injuries from lifting and twisting.

ANS: D Back injuries are the most common injury in health care workers, and in many cases, they are preventable through use of proper body mechanics.

One of the facilitys unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to: a. use an emery board to smooth the nail edges. b. use scissors to round off the nail near the end of the toe. c. apply lotion to the feet and apply bed socks. d. cut the nail straight across with a nail clipper.

ANS: D Cutting the nails straight will prevent ingrown toenails.

In assessing the skin condition of an elderly patient, the nurse notes that, over the sacral area, there is a 2-cm 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be: a. Patient has stage II ulcer on sacrum. No blanching of perimeter. b. Reddened area over sacrum, skin open in center. c. Pressure ulcer on sacrum. Massaged with no improvement in color. d. 2-cm 3-cm reddened area on sacrum with open center. Does not blanch.

ANS: D Description of a pressure ulcer should be specific and give a visual picture of the area. Such documentation will be useful in calculating the Medicare reimbursement for the facility.

An important factor to consider when assessing the hygiene needs of a patient is that: a. the patient knows best what is needed in his hygiene routine. b. the routine of the agency will determine when the patient is able to bathe. c. hygiene is not as important as other needs of the patient. d. the patient may not have the same hygiene practices as the nurse.

ANS: D Different cultures have different views of hygiene practices, such as use of deodorant, shaving, or daily bathing. These needs are an important part of health and recovery from illness.

When providing perineal care for an uncircumcised male patient, the nurse: a. provides perineal care the same as for a circumcised male. b. ensures that the foreskin is retracted and the glans is exposed at the end of the procedure. c. does not touch the glans during the procedure because it is very sensitive. d. retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure.

ANS: D In the uncircumcised male, the foreskin covers the glans and must be retracted to adequately cleanse the secretions that accumulate under the foreskin and can lead to infection. The foreskin must be pulled down to cover the glans after cleaning or it can swell and cause pain and constriction of the glans.

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should: a. massage the areas vigorously to restore circulation to the pressured areas. b. document that the patient has a stage I pressure ulcer of the right shoulder and hip. c. not position the patient on the right side for at least 8 hours. d. reassess the area after 30 to 45 minutes for reactive hyperemia.

ANS: D Redness and nonblanching that remain after relief of pressure for 30 to 45 minutes are an indication of a stage I pressure ulcer. Therefore the area needs to be reassessed before it is labeled a stage I pressure ulcer.

An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to: a. raise the knees to keep the patient from sliding down. b. position the patient on her side and use protective wrist and vest devices to keep her from turning onto her back. c. assist the patient to sit in a wheelchair for short periods before returning her to bed. d. place the patient on her stomach (prone position) using a small pillow below her diaphragm.

ANS: D The prone position is an excellent (but underused) position to take pressure off the sacral area. Raising the head and the knees of the patient interferes with venous return from the legs and puts a great deal of pressure on the sacrum. Use of a wheelchair for a semiconscious patient is not effective.

To provide correct body alignment for a physically immobile patient in bed in the supine position, the nurse: a. uses trochanter rolls between the patients legs to prevent inward rotation. b. places a large pillow behind the patients head and neck to hyperflex the neck. c. raises the head and knees to maintain as much flexion of the hips and knees as possible. d. uses a footboard or places high-top sneakers on the patients feet to maintain dorsiflexion.

ANS: D The use of high-top sneakers (or a footboard) prevents footdrop and maintains dorsiflexion.

induration

areas of skin feel hard

halitosis

bad breath

hygiene

cleanliness that is conductive to preservation of health

tendons

cords of fibrous connective tissue connect muscle to bone and allow join movement

bone

dense & hard types of connective tissue

caries

dental cavities

melanin

determination of skin color

semi-fowler position

elevate head 30-60 degree knees can be up to 15 degrees

fowler position

elevating head of bed 60-90 degrees

symmetry

equal in size, form, arrangement on opposite sides of plane, mirror imagine

syncope

fainting

cartilage

fibrous connective tissue acts as a cushion

side-lying (lateral) position

resting on side

There are two main factors in the development of pressure ulcers. One is pressure and the other is _________________.

shear force

sims position

side lying, weight distributed over anterior ilium, humerus, clavicle

dangling

sitting on side of bed w/legs & feet hanging on side

eschar

slough produced by thermal burn corrosive material/gangrene

bursa

small fluid sac provides cushion at fricken points in freely moveable joints

maceration

softening of tissue and increase chance of trauma infection

alignment

straight line, bringing line to order

skeletal muscles

striated muscles made of bundles of muscle fibers surrounded by connective tissue sheath

ligaments

strong fibrous connective tissue support/ strengthens bones of joints

kinesiology

study of movement of body parts, body mechanics

transfer belt

sturdy belt used to ambulate/ transfer weak patients

gait

style of walking

integumentary

system containing skin, hair, nails, sweat and sebaceous glands

ambulate

to walk

logrolling

turn patient as a single unit in bed, maintain alignment

pivot

turn/change position w/ feet while fixed in place

joint

union of 2+ bones in body

ceremen

waxy substance secreted by ceruminous glands (earwax)