Fundamentals EAQ's Ch 40

A registered nurse teaches a group of nursing students about critical thinking. Which statement if made by the nursing student indicates the need for further learning?

"Clinical judgments and decisions should be made before anticipating the information." Rationale Clinical judgments should be made after analyzing the data and not before anticipating the information.

Which action performed by the nurse is inappropriate while implementing care to patients in a health care facility?

Being judgmental and confident while providing care Rationale While providing hygienic care, the nurse should be nonjudgmental and confident.

Which chronic diseases often incapacitate patients?

Cancer Pulmonary disease Neurological disease Rationale Cancer, pulmonary disease, and neurological disease are chronic diseases that often incapacitate patients.

An 86-year-old patient visits the primary health care provider with a complaint of dry and itchy skin. What could be the cause of this condition?

Decreased production of lubricating substances Aging causes the production of lubricating substances from the skin to decrease, which leads to dry and itchy skin.

Which condition is caused by tooth decay?

Dental caries Rationale Dental caries are caused by tooth decay.

While caring for a patient, a nurse finds that the patient is untidy and is uninterested in hygiene. What should the nurse do in this situation?

Educate the patient about hygiene. Assess the patient's ability to perform daily hygiene practices. Rationale Patients who appear untidy or uninterested in hygiene should be educated about the importance of hygiene. The nurse should also determine the patient's ability to perform daily hygiene.

A nurse cares for a patient who has arthritis. Which questions should the nurse ask to determine the patient's religious and cultural practices?

How can I best help you with hair care?" "Do you have any preferences for how you bathe?" "How comfortable are you with my care?" Rationale Asking questions such as which is the best way to provide effective hair care,and what is the patient's bathing preferences are helpful for determining the patient's cultural or religious practices. Some patients may have their limits or preferences regarding hygiene, so the nurse should ask about the patient's comfort zone.

Which statement is true regarding the implications of skin care?

Weakening of the epidermis occurs due to scraping or stripping of the skin's surface. Rationale Scraping or stripping of the skin's surface may be due to a weak epidermis.

Which condition is observed in a patient who has gingivitis?

Inflammation of the gums Rationale Gingivitis is the inflammation of the gums.

Which statement is true regarding subcutaneous tissue?

The subcutaneous layer contains blood vessels, nerves, lymph, and loose connective tissue. Rationale The subcutaneous tissue layer contains blood vessels, nerves, lymph, and loose connective tissue.

A registered nurse teaches a nursing student about cultural beliefs and personal values that may influence hygiene. Which statement if made by the nursing student indicates the need for further teaching?

"All socioeconomic groups are sensitive to body odors." Rationale Some socioeconomic groups are not sensitive to body odors, and they prefer to bathe less frequently.

A registered nurse teaches a nursing student about patient-centered care in hygiene practice. Which statements, if made by the nursing student, indicates the need for further learning?

"I can uncover the lower torso of women of Middle Eastern or East Asian descent." "I should understand that toileting practices are equal in all cultures." Rationale The nurse should avoid uncovering the lower torso of patients of Middle Eastern and East Asian descent. The nurse should understand that toileting practices differ by culture.

A registered nurse teaches a nursing student about body image and hygiene. Which statement if made by the nursing student indicates the need for further teaching?

"I should force the patient to perform hygiene practices." Rationale The nurse should avoid forcing the patient to perform hygiene practices unless the issue directly affects a patient's health.

A registered nurse teaches a patient about skin protection. Which statement made by the patient indicates the need for further teaching?

"I should keep my bed linens and clothing wet." Rationale The patient's bed linens and clothing should be kept dry to protect the skin.

A registered nurse teaches a nursing student about the implications of skin care. Which statement if made by the nursing student indicates a need for further learning?

"I should maximize friction by moving the patient frequently." Rationale Friction should be minimized to reduce the risk of pressure ulcers.

A registered nurse teaches a nursing student about the characteristics of hair. Which statement if made by the nursing student indicates a need for further teaching?

"Physiological factors directly affect the hair shaft." Rationale Physiological factors do not directly affect the hair shaft.

A registered nurse teaches a nursing student about different developmental stages of the skin. Which statements, if made by the nursing student, indicates the need for further learning?

"The epidermis and dermis of neonates are tightly bound together." "Sweat glands become fully functional when the individual becomes an adult." Rationale In neonates, the epidermis and dermis are loosely bound together and the skin is very thin. Sweat glands become fully functional during puberty.

The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "For the past few weeks, I have been perspiring a lot, especially in the underarm area. What should I do?" Which is the most appropriate response by the nurse?

"This is just a normal part of growing up." Rationale Adolescents tend to sweat more as they reach puberty due to the fact that the sweat glands become very active during this phase. The nurse should explain to the student that this is not an abnormal phenomenon.

Which instruction provided by the nurse would be most beneficial to a patient who underwent bariatric surgery?

"You should use adaptive bathing methods." Rationale Adaptive bathing methods are beneficial for patients who undergo bariatric surgery.

A patient reports cracks in the skin. Which suggestion would be beneficial for the patient?

"You should use emollients." Rationale Cracks in the skin are caused by dryness. This condition can be prevented by using emollients to soften the skin and prevent moisture loss.

Which suggestion made by the nurse is appropriate for reducing mechanical irritation?

"You should use smooth linen cloths." Rationale The use of smooth linen cloths can reduce mechanical irritation.

Which patient is more prone to ulcer formation on the skin?

A patient using moisturizers Rationale A patient using moisturizers is more prone to ulcer formation on the skin. Constant exposure of the skin to moisture causes maceration, which promotes ulcer formation.

A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior, such as screaming and hitting during the bath. Which techniques would make the bathing experience less stressful for both the nurse and the patient?

Allow the patient to perform as much of the care as possible. Try an alternative to traditional bathing, such as the bag bath. Rationale Patients with cognitive impairment may respond to bathing by acting out aggressively. Studies have indicated a number of triggering events, including washing the face first. The bag bath has been shown to result in a lower incidence of aggressive behavior than traditional bathing. Use of restraints is not warranted and can actually lead to injury, because the patient often fights against the restraints. Cognitively impaired patients respond better when the nurse uses a gentle approach and avoids rushing.

A patient reports dry and flaky skin. During an assessment, the nurse notices a loss of protective oils from the skin. What are possible reasons for the patient's condition?

Bathing frequently Using hot water frequently Rationale If the patient bathes and uses hot water frequently, the skin may become dry and flaky and it may lose protective oils.

While assessing a patient, the nurse finds maceration on the skin. What could be the reason for this condition?

Constant exposure to moisture Rationale Maceration is defined as the softening and breaking down of the skin. Constant exposure of the skin to moisture leads to maceration.

What are common foot problems in older adults?

Corns Calluses Bunions Rationale Corns, calluses, and bunions are common foot problems in older adults.

An elderly patient complains of itching. On examination, the nurse finds that the patient's skin is dry and flaky. The patient bathes frequently. The patient has no other complaints. What should the nurse tell the patient to do?

Decrease bathing frequency with soap. Rationale The skin of old people is prone to dryness due to decreased production of protective lubricating substances. The nurse should advise this patient to avoid taking frequent baths with soap to prevent excessive dryness and itching.

Which factors impair salivary secretions?

Dehydration Effects of medication Exposure to radiation Rationale Factors that impair salivary secretions include dehydration, effects of medication, and exposure to radiation.

An 82-year-old patient visits the primary health care provider with a complaint of dry feet. Which conditions are responsible for the patient's condition?

Dehydration of epidermal cells Decrease in sebaceous gland secretions Rationale The dehydration of epidermal cells and a decrease in sebaceous gland secretions can lead to dry feet in older adults.

While assessing a patient's oral cavity, the nurse finds tooth decay. Which condition does the nurse suspect?

Dental caries Rationale Tooth decay may be produced by the interaction of food with bacteria; this condition is known as dental caries.

Which condition impairs the healing function of skin?

Diabetes mellitus Rationale Diabetes mellitus can impair the healing function of the skin due to chronic vascular changes.

In which part of the skin do the normal flora reside?

Epidermis Rationale Normal flora reside in the outer epidermis.

Which statements are true regarding implication of cultural aspects of hygiene practice?

Family members are allowed to participate in care. Gender-congruent caregivers should be provided if requested. Rationale The cultural aspects of hygiene practice include allowing the family members to participate in care, if desired, by adapting the schedule of hygiene activities. It also includes providing gender-congruent caregivers if requested or needed.

While assessing a patient, the nurse finds inflamed gums. What would the nurse document in the patient's medical chart?

Gingivitis Rationale Inflammation of gums is known as gingivitis.

While caring for a patient, the nurse instructs the patient to perform oral hygiene at least twice a day. Which conditions is the nurse preventing the patient from developing?

Gingivitis Dental caries Periodontal disease Rationale Performing oral care at least twice a day and flossing reduces the risk of gingivitis, dental caries, and periodontal disease.

The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response?

Help the patient return to bed. Rationale The report of fatigue and rapid respirations and pulse indicate that the patient is not tolerating the activity and needs to rest.

Which statement is true about the development stage of adolescents?

In girls, the skin becomes soft with increased vascularity. Rationale In girls, estrogen secretion causes the skin to become soft and thicker with increased vascularity.

What is the reason for the development of acne in adolescents?

Increased inflammation of sebaceous glands Rationale Active inflammation of sebaceous glands leads to the formation of pimples; this condition is called acne.

What is the name of the crescent-shaped white area present in the nail body?

Lunula Rationale The crescent-shaped white area of the nail body is called the lunula.

A 43-year-old women who is obese reports frequent burning and numbness of the feet. The patient also has foot pain when standing for a long time. Which condition would the nurse suspect?

Morton's neuroma Rationale Burning, numbness, and pain in the feet when standing for a long period of time are symptoms of Morton's neuroma. It is a common condition in middle-aged women who are overweight.

What is a common foot problem that affects middle-aged women?

Morton's neuroma Rationale Morton's neuroma is a common condition that affects middle-aged women; this condition causes burning, numbness, and foot pain.

Which symptom often changes a patient's gait?

Pain Rationale Pain often changes a patient's gait.

After assessing the patient's foot, the primary health care provider concludes that the patient has Morton's neuroma. Which symptoms are associated with this condition?

Pain in the foot Burning of the foot Numbness of the foot Rationale Morton's neuroma is a common condition that affects middle-aged women. Symptoms include foot pain and numbness and a burning sensation in the foot.

While assessing a patient, the nurse observes that the patient has a dry cornea. What may be the cause of this condition?

Paralysis of the trigeminal nerve Rationale Paralysis of the trigeminal nerve eliminates the blink reflex, which causes corneal drying.

Which structure helps to hold a tooth firmly in place?

Periodontal membrane Rationale The periodontal membrane lies below the gum margins, surrounds the teeth, and holds the teeth firmly in place.

The nurse is monitoring an older adult patient who has undergone coronary artery bypass graft (CABG) for blocked blood vessels of the heart. Which dermatological findings in the patient indicate healthy skin?

Pink color Supple skin Warm skin Rationale Changes in color, thickness, temperature, and hydration of the skin are various dermatological presentations that help the nurse to differentiate between healthy and unhealthy skin. A pink color indicates healthy skin. Suppleness of the skin indicates that the skin is well hydrated, and warm skin indicates adequate circulation.

The nurse asks the nursing assistive person (NAP) to clean a patient who has been incontinent of urine. Several minutes later the nurse passes the open door of the room and sees the NAP changing the patient's gown and linen. Which requires the nurse's immediate attention?

Room door is open to the hallway. Rationale Leaving the room door open to the hallway violates the patient's privacy.

A licensed practical nurse is caring for a patient under the supervision of a registered nurse. Which action if made by the licensed practical nurse requires a need for further teaching?

Rubbing the patient's skin Rationale Rubbing the patient's skin can create friction and lead to a loss of stratum corneum. This loss may cause the development of pressure ulcers.

While caring for a patient, the nurse suspects improper turning. Which condition does the nurse suspect?

Scraping of the skin Rationale Improper turning or positioning techniques can lead to scraping or stripping of the skin surface.

The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "I have so many pimples on my face, it makes my face look horrible. Can I ever get rid of this problem?" The nurse says, "Pimples are a common problem in adolescents. They are often due to the inflammatory condition of some glands." Which gland is the nurse talking about?

Sebaceous gland Rationale Acne is a common problem in adolescents caused by the active inflammation of the sebaceous glands.

What are indications of diseased nails?

Shape of the nail Thickness of the nail Curvature of the nail Rationale The shape, curvature, and thickness of the nail can indicate diseased nails. A normal healthy nail appears smooth with a pink color nail bed and translucent white tip.

Which statement is true regarding the oral cavity?

Stimulation of the sympathetic nervous system can completely inhibit the release of saliva. Rationale The release of saliva is strongly inhibited when the sympathetic nervous system is strongly inhibited.

While performing hygiene and grooming for a patient, the nurse finds that the patient is exhibiting fear and agitated behavior. What might be the patient's condition?

Stroke Dementia Brain injury Rationale Patients with cognitive impairments are sometimes unaware of their hygiene and grooming needs. They become fearful and agitated during hygiene care, resulting in aggressive behavior. Acute and chronic cognitive impairment conditions that may result in the inability to perform self-care independently include stroke, dementia, and brain injuries.

Which statement is true regarding the skin?

The dermis is formed by bundles of collagen and elastic fibers. Rationale The dermis is a layer of skin formed by bundles of collagen and elastic fibers. It is thick and underlies the epidermis.

Which statement is true regarding the odorous fluid secreted by the sebaceous gland?

The fluid softens and lubricates the skin. Rationale Sebaceous glands secrete sebum, which is an oily odorous fluid that softens and lubricates the skin and slows water loss from the skin when humidity is low.

Which assessment findings inform the nurse that a patient may have difficulty performing activities of self-care independently?

The patient becomes short of breath frequently. The patient has post-operative incisional pain. The patient becomes confused frequently. Rationale Frequent episodes of shortness of breath, confusion or disorientation and post-operative pain all can limit a patient's ability to perform self-care independently. These patients will require some degree of assistance in order to promote good hygiene and patient safety.

Which action made by the patient is associated with the loss of the protective acid condition of the skin?

The patient uses alkaline soaps. Rationale Alkaline soaps neutralize the protective acid condition of the skin.

While caring for a patient with partial dentures who has dental caries, the nurse observes that the patient's gums have lost vascularity and tissue elasticity. Which risk does the nurse suspect?

The patient's dentures cannot fit properly. Rationale Gums lose vascularity and tissue elasticity due to lack of attention to oral care; this may cause the patient's dentures to fit poorly.

Which statements are true regarding the oral cavity?

The saliva facilitates bolus formation. Mouth breathing may impair saliva secretion in the mouth. The mucous membrane, continuous with the skin, lines the oral cavity. Rationale The saliva moistens food and thereby facilitates bolus formation. Medications, exposure to radiation, dehydration, and mouth breathing impair saliva secretion in the mouth. The mucous membrane, continuous with the skin, lines the oral cavity.

What is the significant cause of bleeding in the oral cavity?

Trauma Rationale Trauma is the significant cause of bleeding in the oral cavity.

The nurse is teaching a group of caregivers about methods of skin care. Which instructions should the nurse include in the teachings?

Use emollients. Bathe regularly. Keep bed and linens dry. Rationale Emollients soften skin and prevent moisture loss. Bathing helps to remove excess body secretions. Keeping bed linens and clothing dry helps to prevent development of pressure ulcers.

The nurse advises a patient to avoid the use of dry razors. Which condition is the nurse trying to prevent?

Weakening of the epidermis Rationale The use of dry razors can scrape or strip the skin's surface. Weakening of the epidermis occurs by scraping or stripping the skin's surface