Critical thinking/ Review Questions- Ch 17, 5, 6, 9 for Exam 1

6 Cleaning baths include which of the following? (Select all that apply.) 1 Bed bath 2 Herbal bath 3 Tub bath 4 Shower

1: Bed bath 3: Tub bath 4: Shower Rationale: A bed bath, tub bath, and shower are all considered cleaning baths. An herbal bath is a therapeutic bath because it is ordered for a specific effect.

While giving a complete bed bath to an unconscious patient, care is taken to: 1 Tape the eyelids shut to preserve moisture. 2 Close the eyelids with the back of the fingertip and place a an eye patch or shield in place with tape. 3 Place moistened cotton balls on the eyelids to moisten the eye. 4 Allow the eyelids to stay open to help the nurse identify when the patient has regained consciousness.

2 Close the eyelids with the back of the fingertip and place a an eye patch or shield in place with tape. In the absence of a blink reflex, the eyelids should be kept closed with an eye patch or shield after gently closing the eye with the back of your fingertip. Taping the eyelids closed is not accepted practice; and leaving the eyes open causes excessive dryness of the eye, leading to corneal drying, abrasions, and eye infection.

A nurse is caring for a critically ill cardiac surgery patient who is on a ventilator. Which of the following solutions has been shown to decrease the incidence of ventilator-assisted pneumonia (VAP) in intubated patients? 1 Peroxide 2 Normal saline 3 Chlorhexidine 4 Tap water

3 Chlorhexidine Rationale: Oral care with peroxide is not recommended with mechanically ventilated patients. Normal saline can be used to moisten the mucosa; however, it is not associated with prevention of VAP. Oral care using chlorhexidine has proved to reduce VAP in mechanically ventilated cardiac surgery patients. It has also shown benefit with patients who do not have a pneumonia diagnosis before intubation.

Provide bathing at regular intervals to: 1 Restore normal pH of the skin from acidic to alkaline. 2 Remove resident bacteria that normally cause disease. 3 Clean the outer layer of skin and remove dead skin cells. 4 Promote the maturation of new skin cells.

3 Clean the outer layer of skin and remove dead skin cells. Rationale: Moving a cloth on the skin during bathing not only cleans but also removes dead skin cells.

A Muslim woman needs to have a bed bath. Which adjustment does the female nurse need to make when performing perineal care? 1 She needs to use gloves when performing perineal care. 2 She needs to have another nurse in attendance while doing perineal care. 3 She needs to use her left hand when doing perineal care. 4 She needs to use her dominant hand when doing perineal care

3 She needs to use her left hand when doing perineal care. Rationale: Muslims use the left hand for cleaning the genital area. The right hand is reserved for eating and praying. As long as the caregiver is a woman, it is not necessary to have another woman present. If the nurse is right-handed, she should switch and perform the perineal care using her left hand to show respect for her patient's beliefs. Gloves should be used for all patients when doing perineal care.

Some patients require special positioning precautions when the hair is shampooed. Special positioning precautions are most appropriate for which patient? 1 A patient with diabetes who has hypertension 2 A patient with a hearing deficit 3 A patient who has an endotracheal tube 4 A patient with arthritis in her cervical spine

4 A patient with arthritis in her cervical spine Rationale: A patient with arthritis in her neck may have pain and limited movement. This could cause a problem when her head is turned and repositioned while her hair is washed.

A patient in the intensive care unit after a head injury has been unresponsive at times and can be aroused only after painful stimuli. Which assessment by the nurse is most crucial in determining whether it is safe to perform oral hygiene? 1 Check the patient's pupillary response 2 Evaluate the patient using the Glascow Coma Scale 3 Assess the condition of the oral cavity 4 Determine the presence of a gag reflex

4 Determine the presence of a gag reflex Rationale: Before administering oral care to an unconscious patient, check the gag reflex to determine risk for aspiration. A pupil check indicates if intracranial pressure is developing. The Glasgow Coma Scale measures level of consciousness. It is important to inspect the oral cavity, but this will not reveal any risk for aspiration.

An 88-year-old patient diagnosed with dementia frequently becomes very agitated and aggressive with caregivers. Which approach for bathing this patient would be most appropriate? 1 Help the patient with a shower 2 Provide a complete bed bath 3 Avoid bathing until the patient becomes more relaxed 4 Provide a disposable bed bath in bed

4 Provide a disposable bed bath in bed Rationale: A patient who becomes aggressive or uncooperative would do best with a warm, disposable bath in bed. It provides a more thorough bath in the safest environment for both patient and caregiver.

Inflammation of the mucous membrane of the mouth is called?

Mucositis

Mr. Bank is a 78-year-old male with a 3-year history of type 1 diabetes mellitus and hypertension. He was just discharged after 5 days of hospitalization with diagnoses of healing right-heel ulcer and controlled hypertension. His discharge summary notes that he requires assistance with daily dressing changes for the ulcer. Mr. Bank lives alone and is able to perform all routine activities of daily living (ADLs). During the initial home visit you assess that, although he understands the need for the daily dressing changes, he is not able to state which precautions are needed to prevent any recurrence. Identify a proactive foot-care intervention that Mr. Bank should perform. 1 Self-treat corns and callus with over-the-counter products 2 Seek a professional evaluation by a podiatrist and establish a foot-and-nail care schedule at least annually 3 Cut toenails in a curved shape to the pink part of the nail 4 Wear shoes without socks

The correct answer is 2. Patients with diabetes should have a podiatrist who performs foot and nail care at least annually. Patients should be taught signs and symptoms that warrant the need to seek medical attention.

Mr. Bank is a 78-year-old male with a 3-year history of type 1 diabetes mellitus and hypertension. He was just discharged after 5 days of hospitalization with diagnoses of healing right-heel ulcer and controlled hypertension. His discharge summary notes that he requires assistance with daily dressing changes for the ulcer. Mr. Bank lives alone and is able to perform all routine activities of daily living (ADLs). During the initial home visit you assess that, although he understands the need for the daily dressing changes, he is not able to state which precautions are needed to prevent any recurrence. Which three actions should Mr. Bank do to maintain good foot care? 1 Wear properly fitting shoes 2 Wear clean nylon socks 3 Inspect feet daily, both top and bottom 4 Have nails trimmed by professional 5 Soak feet daily in warm water for 15 minu

The correct answers are 1, 3, and 4. Patients with diabetes should wear socks made of natural fibers to aid in absorption of perspiration. Cotton socks are most commonly recommended. A professional should trim nails to minimize chance of injury and infection. It is recommended that patients with diabetes mellitus should not soak feet for two reasons: (1) decreased sensation in lower extremities caused by peripheral neuropathy makes it difficult to determine temperature; and (2) soaking the feet causes maceration of the skin around the nails and feet, which can cause infection.

A patient requires oral care every 2 hours. Indicate which order should be followed to safely prepare the patient for oral care. 1 Assess environment for safety and provide privacy. 2 Lower side rail. 3 Raise bed to working height. 4 Arrange supplies on over-bed table. 5 Position patient.

The correct order is 1, 4, 3, 2, 5 Rationale: Assessing the environment for safety should always precede care. Making sure that you have your supplies arranged nearby eliminates leaving the bedside and interrupting care. Raising the bed to working height is a necessary part of safe body mechanics to avoid injury to the caregiver. Lowering the side rail allows easy access to the