Fundamentals Nursing Active Learning 1st Edition Yoost Crawford
Fundamentals Nursing Active Learning 1st Edition Yoost Crawford
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Chapter 27: Hygiene and Personal Care
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath. |
| b. | UAPs perform hygiene because there is no benefit of nurses doing it. |
| c. | The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. |
| d. | The main purpose of bathing is to decrease odor. |
ANS:Â A
The bath is an excellent opportunity for the nurse to assess multiple body systems. Although the UAP can perform hygiene, there is benefit to the nurse doing it because of the ability to assess the patient. The mucous membranes are a part of the integumentary system, and bathing cleanses the skin, provides comfort, and contributes to the patient’s health and well-being.
DIF:   Applying       REF:  p. 518           OBJ:  27.01            TOP:  Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity    NOT: Concepts: Caregiving
| a. | Imbalanced Nutrition: Less than body requirements |
| b. | Deficient fluid volume |
| c. | Risk for infection |
| d. | Acute pain |
ANS:Â C
Any interruption in the skin, which is the body’s first line of defense, can potentially lead to infection. Both imbalanced nutrition and deficient fluid volume could have dry skin as a symptom. Acute pain is not appropriate.
DIF:   Evaluating     REF:  p. 519           OBJ:  27.02            TOP:  Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity    NOT: Concepts: Caregiving
| a. | Patient with asthma |
| b. | Patient with attention deficit hyperactivity disorder |
| c. | Patient with a stroke |
| d. | Patient with diabetes |
ANS:Â D
Patients with neurologic deficits such as peripheral neuropathy resulting from diabetes may not be able to identify extremes of hot and cold. Patients with attention deficit hyperactivity disorder and asthma are not likely to be injured by temperature extremes. Patients with a stroke may have some alteration in sensation on one side of their body but can compensate by using the other side, and they are at less risk than a patient with diabetes.
DIF:   Analyzing     REF:  p. 519           OBJ:  27.02            TOP:  Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity    NOT: Concepts: Caregiving
| a. | Braden scale |
| b. | Glasgow scale |
| c. | Vanderbilt scale |
| d. | MMSE scale |
ANS:Â A
The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.
DIF:   Understanding                                REF:  p. 521            OBJ:  27.03
TOP:  Assessment   MSC: NCLEX Client Needs Category: Physiological Integrity
NOT:Â Concepts: Caregiving
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