Module 2 Flashcards
Which piece of clothing would the nurse remove when looking for excoriations?
adult diaper
When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?
open wound over the sacrum
Which type of injury results in a puncture wound?
dog bite
A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?
presence of pediculosis
Which assessment findings are indicative of poor hygiene?
body odors
tangled and matted hair
excessively long and dirty toenails
The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)?
do you always make it to the bathroom on time
how often do you take a bath or shower
can you bathe yourself without help
An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient’s skin for which signs of infection?
redness
swelling
drainage
An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital?
assist the patient with community referrals
Which factors are potential causes of halitosis?
diabetes
medications
poor oral hygiene
infections of the oral cavity
Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care?
partnering with the occupational therapist
Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences?
accommodate the patients wishes
Which questions will the nurse ask when formulating a measurable hygiene and personal care goal?
who will achieve the personal care goal
what action must the patient perform
when will the patient have performed the action
Which example shows a correctly stated hygiene and personal care long-term goal?
patient will shower independently by the end of 1 month
A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing hypothesis would the nurse select?
self-care deficit
A patient is recovering from leg surgery and is unable to stand for self-care. Which hypotheses would be selected for hygiene and self-care?
traumatic wound
self-care deficit
