The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first? correct answers "Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on y...
VNSG 1323: Chapter 17 Prep U Questions || A+ Graded
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The nurse is caring for an older adult client who has refused a bath for several days, and has now
developed a rash on the buttocks. Which statement by the nurse should be made first? correct
answers "Getting a bath helps to remove the bacteria from your skin, which is what is causing
the rash on your buttocks."
Explanation: The client needs education about why bathing is important. Knowledge deficit, and
fear of loss of independence and/or privacy, may be impacting the client's choice. The nurse will
first provide information about the reason that bathing is important, and then assure the client
that privacy will be maintained, empowerment will be given, and autonomy will be respected.
Bathing should be performed in an orderly, head-to-toe manner. correct answers False
A student has been assigned to provide morning care to a client. The plan of care includes
information that the client requires partial care. What will the student do? correct answers
Provide supplies and assist with hard-to-reach areas.
Explanation: Morning care is often identified as either self-care, partial care, or complete care.
Clients requiring partial morning care most often receive care at the bedside or seated near the
sink in the bathroom. They usually require assistance with body areas that are difficult to reach.
The nurse would provide supplies and orient client to the bathroom in self care. Providing
complete care or personal hygiene requires: bathing, showering and washing, foot, hair, nail,
perineal, shaving, mouth and oral, and denture care.
The nurse has completed teaching regarding pediculosis. Which client statement requires further
nursing teaching? correct answers "I will use conditioner so that the lice eggs will slide off my
hair."
Explanation: Hair conditioner coats the hairs and protects the nits. The nurse must intervene to
teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs
¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct
contact.
An elderly client has worn an artificial eye since advanced glaucoma necessitated enucleation
(removal of the eye). What action should the nurse perform immediately before assisting the
client with resinsertion of the artificial eye? correct answers Gently rinse the client's eye socket
with clean water or normal saline.
Explanation: The nurse irrigates the eye socket with water or saline before reinserting the
artificial eye. Antibiotic ointments and petroleum jelly are not applied to the artificial eye and
lubricants are not applied to the client's eye socket.
, A nurse is brushing the hair of a client admitted to the health care facility following a fracture in
the hand. The nurse implements this action based on the understanding that brushing the hair:
correct answers Facilitates oil distribution
Explanation: Brushing the hair facilitates oil distribution along the hair shaft more effectively
than combing, as well as massages the scalp and stimulates circulation. Shampooing cleans the
hair and scalp, helps get rid of excess oil, and cleans the hair of dirt. It provides a relaxing,
soothing experience for the client.
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse
provide? correct answers Use electric razor for shaving purposes.
Explanation: Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, in
place of a safety razor, and a soft bristle toothbrush will reduce bleeding during care of skin and
gums. The client should not be advised to take aspirin, buy a hard-bristle toothbrush, or explain
that prolonged bleeding is normal.
Which statement made by the client, regarding flat patches of brown skin on the face,
demonstrates understanding? correct answers "These brown spots are senile lentigines and are
common when you get older."
Explanation: Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and
senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older
adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratosis, as
these spots are raised in appearance. The spots are not likely cancer and do not need to be
removed.
An older adult client with Parkinson's disease is unable to take care of himself. The client
frequently soils his bed and is unable to clean himself independently. How should the nurse in
this case ensure the client's perineal care? correct answers Cleanse to remove secretions from
less-soiled to more-soiled areas.
Explanation: To ensure proper perineal care, the nurse should cleanse to remove secretions and
excretions from least contaminated area to the most contaminated area. The nurse must also
prevent direct contact with any secretions or excretions by wearing clean gloves. The nurse
should not use cotton cloth or tissues to clean the perineal area because that might lead to skin
impairment. Older adult clients have sensitive skin, which may be easily impaired when
cleaning. Because the client cannot do anything independently, providing him with a bed pan or
a jar will not help.
The nurse is preparing to perform perineal care on an uncircumcised adult male client who was
incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for
cleaning the penis is correct? correct answers Retract the foreskin while washing the penis; then,
immediately pull the foreskin back into place.
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