Exam 1 Practice - Fundamentals of Nursing Part 2

Communication – Chp 8. b. c. d. 1. During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse’s BEST response? “You need to speak to the patient quietly so you don’t disturb the other patients.” “Let me help you with your transfer technique.” “When you are finished, be sure to apologize for your rough demeanor.” “When your patient is safe and comfortable, meet me at the desk.” a. b. c. d. 2. A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, “How is she doing, since the baby’s father is no help?” What is the nurse’s BEST response to the neighbor? “New mothers need support.” “The lack of a father is difficult.” “How are you today?” “It is a very sad situation.” a. 3. A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions 4. A nurse enters a patient’s room and examines the patient’s IV fluids and cardiac monitor. The patient states, “Well, I haven’t seen you before. Who are you?” What is the nurse’s BEST response? a. “I’m just the IV therapist checking your IV.” b. “I’ve been transferred to this division and will be caring for you.” c. “I’m sorry, my name is John Smith and I am your nurse.” d. “My name is John Smith, I am your nurse and I’ll be caring for you until 11 PM.” 5. A nurse enters the room of a patient with cancer. The patient is crying and states, “I feel so alone.” Which response by the nurse is the most therapeutic action? a. The nurse stands at the patient’s bedside and states, “I understand how you feel. My mother said the same thing when she was ill.” b. The nurse places a hand on the patient’s arm and states, “You feel so alone.” c. The nurse stands in the patient’s room and asks, “Why do you feel so alone? Your wife has been here every day.” d. The nurse holds the patient’s hand and asks, “What makes you feel so alone?” a. b. c. d. 6. A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? Determining the progress made in achieving established goals Clarifying when the patient should take medications Reporting the progress made in teaching to the staff Including all family members in the teaching session e. f. g. h. 7. A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student’s provision of patient care? Determining the established goals of the institution Ensuring that verbal and nonverbal communication is congruent Engaging in self-talk to plan the day and decrease fear Speaking with fellow colleagues about how they feel i. j. k. l. 8. A nurse in the rehabilitation division states to the head nurse: “I need the day off and you didn’t give it to me!” The head nurse replies, “Well, I wasn’t aware you needed the day off, and it isn’t possible since staffing is so inadequate.” Instead of this exchange, what communication by the nurse would have been more effective? “I placed a request to have 8th of August off, but I’m working and I have a doctor’s appointment.” “I would like to discuss my schedule with you. I requested the 8th of August off for a doctor’s appointment. Could I make an appointment?” “I will need to call in on the 8th of August because I have a doctor’s appointment.” “Since you didn’t give me the 8th of August off, will I need to find someone to work for me?” a. b. c. d. e. f. 9. During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. Group decision making Group leadership Group power Group identity Group patterns of interaction Group cohesiveness a. b. c. d. 10. A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? Pain Anxiety Depression Fluid volume deficit a. b. c. d. 11. A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? “Would you prefer a bath or a shower?” “May I help you with a bed bath now or later this morning?” “I will be giving you your bath. Do you use soap or shower gel?” “I prefer a shower in the evening. When would you like your bath?” a. b. c. d. 12. A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, “What type of foods should I avoid to prevent gas?” The patient’s question allows for what type of communication on the nurse’s part? A closed-ended answer Information clarification The nurse to give advice Assertive behavior a. b. c. d. 13. When interacting with a patient, the nurse answers, “I am sure everything will be fine. You have nothing to worry about.” This is an example of what type of inappropriate communication technique? Cliché Giving advice Being judgmental Changing the subject a. b. c. d. 14. A patient states, “I have been experiencing complications of diabetes.” The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? “Do you take two injections of insulin to decrease the complications?” “Most health care providers recommend diet and exercise to regulate blood sugar.” “Most complications of diabetes are related to neuropathy.” “What specific complications have you experienced?” 15. During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. a. b. c. d. e. f. Fill the silence with lighter conversation directed at the patient. Use the time to perform the care that is needed uninterrupted. Discuss the silence with the patient to ascertain its meaning. Allow the patient time to think and explore inner thoughts. Determine if the patient’s culture requires pauses between conversation. Arrange for a counselor to help the patient cope with emotional issues. ANSWERS WITH RATIONALES 1. d. The charge nurse should direct the patient care technician to determine the patient’s safety. Then the nurse should address any concerns regarding the patient care technician’s communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication. 2. a. The nurse must maintain confidentiality when providing care. The statement “New mothers need support” is a general statement that all new parents need help. The statement is not judgmental of the family’s roles. 3. d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient’s comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person’s feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication. 4. d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient. 5. d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely. 6. a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient’s care. 7. c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety. 8. b. Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time. 9. a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes. 10.a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. 11.b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient’s private zones. 12.b. The patient’s question allows the nurse to clarify information that is new to the patient or that requires further explanation. 13.a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient’s condition. 14.d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques. 15.c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect Safety – Chp. 27 a. b. c. d. e. f. 1. The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A patient who is older than 50 A patient who has already fallen twice A patient who is taking antibiotics A patient who experiences postural hypotension A patient who is experiencing nausea from chemotherapy A 70-year-old patient who is transferred to long-term care e. f. 2. A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. Sixty percent of U.S. fire deaths occur in the home. Most fatal fires occur when people are cooking. Most people who die in fires die of smoke inhalation. Fire-related injury and death have declined due to the availability and use of smoke alarms. Fires are more likely to occur in homes without electricity or gas. Fires are less likely to spread if bedroom doors are kept open when sleeping. a. b. c. d. 3. A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? A toddler playing with his 9-year-old brother’s construction set A 4-year-old eating yogurt for lunch An infant covered with a small blanket and asleep in the crib A 3-year-old drinking a glass of juice a. b. c. d. 4. While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired gas exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for suffocation related to unfamiliarity with fire prevention guidelines d. a. b. c. d. a. b. c. d. Deficient knowledge related to lack of follow-through of recommendation to stop smoking 5. A nurse working in a pediatrician’s office receives calls from parents whose children have ingested toxins. What would be the nurse’s best response? Administer activated charcoal in tablet form and take child to the ED. Administer syrup of ipecac and take child to the ED. Bring the child in to the primary care provider for gastric lavage. Call the PCC immediately before attempting any home remedy. 6. A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. Children older than 6 years may be restrained using a car seat belt in the back seat. a. b. c. d. 7. Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse’s priority intervention to prevent trauma when caring for older adults in a nursing home? Checking to make sure fire alarms are working properly. Preventing exposure to temperature extremes. Screening for partner or elder abuse. Making sure patient rooms are decluttered. a. b. c. d. 8. What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? They prevent confused patients from wandering. A history of a previous fall from a bed with raised side rails is insignificant. Alternative measures are ineffective to prevent wandering. A person of small stature is at increased risk for injury from entrapment. a. b. c. d. 9. When a fire occurs in a patient’s room, what would be the nurse’s priority action? Rescue the patient. Extinguish the fire. Sound the alarm. Run for help. a. b. c. d. 10. A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? The nurse includes suggestions on how to prevent the incident from recurring. The nurse provides minimal information about the incident. The nurse discusses the details with the patient before documenting them. The nurse records the circumstances and effect on the patient in the medical record. 11. When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. c. d. a. b. c. d. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. Even small doses of radiation result in bone marrow depression and cancer. BLI is a serious consequence following detonation of an explosive device. 12. An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? Sitting him in a geriatric chair near the nurses’ station Using the sheets to secure him snugly in his bed Keeping the bed in the high position Identifying his door with his picture and a balloon d. 13. The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? The nurse positions a patient in a supine position prior to applying wrist restraints. The nurse ensures that two fingers can be inserted between the restraint and patient’s ankle. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. The nurse ties an elbow restraint to the raised side rail of a patient’s bed. a. b. c. d. 14. A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? Explain how to use the telephone. Introduce the patient to her roommate. Review the hospital policy on visiting hours. Explain how to operate the call bell. a. b. c. ANSWERS WITH RATIONALES 1. b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics. 2. c, d, e. Of all fire deaths in the United States, 80% occur in the home. Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the significant decline in fire-related injury and death. People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Bedroom doors should be kept closed when sleeping and monitors used to listen for children. 3. a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks. 4. c. Because the patient is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation. 5. d. The nurse should tell the parents to call the PCC immediately, before attempting any home remedy. Parents may be instructed to bring the child immediately to an emergency facility for treatment. Activated charcoal is considered the most effective agent for preventing absorption of the ingested toxin. It is not recommended for storage or use at home. Activated charcoal can be administered through a nasogastric tube in the ED for serious poisonings after the risks and benefits have been determined. Syrup of ipecac is no longer recommended because vomiting may be dangerous. A toxic substance may prove more hazardous coming up rather than when it was swallowed. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small. 6. a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat. 7. d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults. 8. d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient’s dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident. 9. a. The patient’s safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate. 10.d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient’s response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident, and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports. 11.d. BLI is a recognized consequence following exposure to an explosive device. The CDC is the federal facility that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one third of survivors) may exhibit posttraumatic stress disorder. 12.d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall. 13.b. The nurse should be able to place two fingers between the restraint and a patient’s wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered. 14.d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury. Hygiene – Chp. 31 a. b. c. d. a. b. c. d. e. f. a. b. c. d. a. b. c. d. e. f. a. b. c. d. e. f. 1. A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient’s personal hygiene? When the patient had his or her most recent bath The patient’s usual hygiene practices and preferences Where the bathing fits in the nurse’s schedule The time that is convenient for the patient care assistant 2. A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. It promotes the patient’s sense of well-being. It prevents deterioration of the oral cavity. It contributes to decreased incidence of aspiration pneumonia. It eliminates the need for flossing. It decreases oropharyngeal secretions. It helps to compensate for an inadequate diet. 3. A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always “itchy.” Which nursing action would be the nurse’s best response? Bathe the patient more frequently. Use an emollient on the dry skin. Massage the skin with alcohol. Discourage fluid intake. 4. A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A patient who is taking antibiotics for chronic bronchitis A patient diagnosed with type II diabetes A patient who is obese A patient who has a nervous habit of biting his nails A patient diagnosed with prostate cancer A patient whose job involves frequent handwashing 5. Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. Compare bilateral parts for symmetry. Proceed in a toe-to-head systematic manner. Use standard terminology to report and record findings. Do not allow data from the nursing history to direct the assessment. Document only skin abnormalities on the patient record. Perform the appropriate skin assessment when risk factors are identified. a. b. c. d. e. f. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. e. f. a. b. c. d. 6. A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. Wash the skin twice a day with a mild cleanser and warm water. Use cosmetics liberally to cover blackheads. Use emollients on the area. Squeeze blackheads as they appear. Keep hair off the face and wash hair daily. Avoid sun-tanning booth exposure and use sunscreen. 7. A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse’s next action? Make a recommendation for the patient to see an oral surgeon. Report the condition to the primary care provider. Gently scrape the oral cavity with a tongue depressor. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa. 8. A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse’s first action in this procedure? Apply gentle pressure on the lower eyelid to center the lens prior to removing it. Move the eyelids toward one another to cause the lens to slide out between the eyelids. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. Have the patient look forward, retract the lower lid, and move the lens down on the sclera. 9. A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient’s eyes? Use hydrogen peroxide on a clean washcloth to wipe the eyes. Wipe the eye from the outer canthus to the inner canthus. Position the patient on the opposite side of the eye to be cleansed. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean. 10. A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. Bathe the feet thoroughly in a mild soap and tepid water solution. Soak the feet in warm water and bath oil. Dry feet thoroughly, including the area between the toes. Use an alcohol rub if the feet are dry. Use an antifungal foot powder if necessary to prevent fungal infections. Cut the toenails at the lateral corners when trimming the nail. 11. A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? Shift the focus of the interaction to the “process of bathing.” Wash the face and hair at the beginning of the bath. Consider using music to soothe anxiety and agitation. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar. a. b. c. d. e. f. a. b. c. d. a. b. c. d. a. b. c. d. 12. A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. For male and female patients, wash the groin area with a small amount of soap and water and rinse. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. For male and female patients, always proceed from the most contaminated area to the least contaminated area. For male and female patients, use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis. 13. A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? Add bath oil to the water to prevent dry skin. Allow the patient to lock the door to guarantee privacy. Assist the patient in and out of the tub to prevent falling. Keep the water temperature very warm because older adults chill easily. 14. A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient’s gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. Cut the gown with scissors to allow arm movement. Thread the bag and tubing through the gown sleeve, keeping the line intact. Temporarily disconnect the tubing from the IV container, threading it through the gown. 15. A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient’s piercings? Do not remove or wash the piercings without permission from the patient. Rinse the sites with warm water and remove crusts with a cotton swab. Wash the sites with alcohol and apply an antibiotic ointment. Remove the jewelry and allow the sites to heal over. ANSWERS WITH RATIONALES 1. b. Bathing practices and cleansing habits and rituals vary widely. The patient’s preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient’s personal hygiene. The availability of staff to assist may be important, but the patient’s preferences are a higher priority. 2. a, b, c. Adequate oral hygiene is essential for promoting the patient’s sense of wellbeing and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition. 3. b. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin. 4. b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. 5. a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. 6. a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection. 7. d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor. 8. a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye. 9. d. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean. 10.a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails. 11.c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the “task of bathing” to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and selfesteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing “body sections” one day at a time are other possible options. 12.a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. 13.c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity. 14.c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency. 15.b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)