Chapter 19: Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Chapter 19: Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:

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.

DIF:    Cognitive Level: Comprehension      REF:    p. 296              OBJ:    Theory #1

TOP:    Skin Integrity                                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

2. 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:

ANS:   C

Diaphoresis (sweating) is the body’s normal response to rid itself of heat. Drinking fluids to replace those lost prevents dehydration.

DIF:    Cognitive Level: Application             REF:    p. 296              OBJ:    Theory #1

TOP:    Fluid Replacement                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

3. 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:

ANS:   C

Older adults 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 patient’s unsteadiness, it is not safe to have him shower alone.

DIF:    Cognitive Level: Application             REF:    p. 301              OBJ:    Theory #6

TOP:    Hygiene and Safety                            KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

4. In assessing the skin condition of an older adult 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:

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.

DIF:    Cognitive Level: Application             REF:    p. 300

OBJ:    Clinical Practice #2                            TOP:    Pressure Ulcers

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

5. When instructing a nursing assistant about hygiene needs of a frail older adult patient, the nurse correctly educates the nursing assistant to:

ANS:   A

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

DIF:    Cognitive Level: Knowledge             REF:    p. 301              OBJ:    Theory #6

TOP:    Skin Care        KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort