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NUR215 Combined Exam 2 With Questions And Accurate Answers A+ Graded 100% Pass
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NUR215 Combined Exam 2 With Questions And AccurateAnswers A+ Graded 100% Pass
When giving a full bath, which of the following do you wash first? Which do you wash
last? - ANWER First: face, Last: genitals (perineal area)
When would you not use a straight razor on a client? - ANWER Clients prone to bleeding,
clients receiving anticoagulants, those with low platelet count, diabetics, and high
doses of aspirin
When would you not want to use an electric razor? - ANSWER Client is on oxygen
diabetic foot care : - ANSWER Do not use nail clippers, do not soak feet, cut nails
straight across and use file, cannot put lotion between toes or fingers, podiatrist can cut
their nails, tell them to check their feet for sores or cut. Take a bath in lukewarm water.
Dry feet especially between the toes. Avoid using over-the-counter products such as
those containing alcohol for the foot care of patients with diabetes. Wear clean socks
every day. Watch shoes that may lead to injury. Avoid self-treatment of corns or
calluses. Avoid applying heat to the feet. If indications of infection or inflammation are
present, notify the provider.
Partial Bath Who would need a partial bath? ANSWER Partial bath: Those clients who
cannot tolerate a complete bath need special cleaning of malodorous or uncomfortable
areas, or are able to perform part of the bath independently
Complete Bath Who would need a complete bath? ANSWER Complete bath: Those
clients who can tolerate it and whose hygiene needs warrant it
Care of the Oral Cavity Provide oral care for the unconscious patient. ANSWER Suction
apparatus to prevent aspiration. Do not place your fingers into an unconscious clients
mouth because the client could bite down on your finger. Place the client on one side
with the head turned toward you in either a semi-Fowlers position, or with the head of
the bed flat. This will allow fluid and oral secretions to collect in the dependent side of
,the clients mouth and drain out. A small oral airway or a padded tongue may be used to
maintain the openness of the mouth while care is provided. Why are older patients at
higher risk for skin breakdown? - ANSWER Skin is drier and thinner, incontinence,
minimal collagen production Therapeutic Bath What is the purpose of a therapeutic
bath? - ANSWER Promote comfort and provide treatment-sooth itchy skin Skin
disorders, burns, elevated body temperature muscular injuries. Rectal or perineal
surgery, a sitz bath is given to reduce pain and inflammation (providers order)
Discharge teaching for a patient with diabetes related to foot care includes
- ANSWER Do not soak the feet because of the risk of infection and do not cute the nails.
File them using a nail file. Do not apply lotion between the toes because the moisturizer
can cause skin irritation and breakdown. The water should be lukewarm, and the feet
should be well dried. Socks should be changed every day. Those shoes that cause
injuries should be checked to avoid further insult. Self-treatment of corns or calluses
should be avoided. Heat should not be applied. Call provider if any signs of infection or
inflammation are present. How do you care for your denture? - ANSWER To clean
dentures over a sink, first put a towel or washcloth in the bottom of the sink to prevent
breakage if you happen to drop them.
When rinsing the dentures, cool or tepid water should be used. Avoid the use of hot
water since heat may cause softening of the material in some dentures. If they are
stained, soak them in a cleaner. If there are any metal pieces, avoid soaking them
overnight because this may cause corrosion. Rinse well. When not worn, store in a small
amount of water in a denture cup or in a container with a lid. Label cup with patient's
name and room number store in safe place to prevent loss. Return them as soon as
possible. If dentures are dry, wet with water prior to returning them What is a risk for
skin breakdown? - ANSWER Wrinkled sheets, elderly, immobility, poor health,
incontinence, prolonged exposure to urine and stool friction shear-sliding down in bed
What is an example of personal care that can be delegated to an UAP? ANSWER Bathing
What are some non-pharmacological interventions you can do to help promote pain
reduction?
ANSWER Linens should be smooth and clean, and avoid positioning the client on tubing
or equipment that may cause discomfort.
,Position client in anatomic position utilizing gentle repositioning techniques, and
reposition the client frequently to reduce the potential of discomfort. Teach the client
the use of strategies to decrease pain, including: Cognitive-behavioral interventions:
alterations in thought processes about pain Cutaneous (skin) stimulation: heat, cold,
therapeutic touch, massage Distractions: walking around, deep breathing, visitors,
television, games, prayer, and music Relaxation techniques: meditation, yoga,
progressive muscle relaxation Imagery: concentration on a pleasant thought
Acupuncture and acupressure Reducing noxious stimuli Elevation of edematous
extremity: promotes venous return and reduces swelling. How would you care for a
patient with aphasia? (inability to understand or express speech due to injury of the
brain) - ANSWER Ensure only one person speaks at one time.
Long periods of time for client response. Use short sentences with simple words. Pause
between phrases, allowing clients to process what is said Check for comprehension.
Inform clients when you do not understand. Supplement verbal communication with
non-verbal. Use pictures or charts. Acknowledge frustration How would you care for a
client who is hard of hearing? ANSWER Sit and face the client. Do not cover your mouth
when talking to them. Encourage the use of hearing devices. Speak slowly and clearly.
Try lowering vocal pitch before increasing volume. Use brief sentences with simple
words. Write down what they do not understand. Minimize background noise. Ask for a
sign-language interpreter, if necessary. Do not shout How would you communicate with
a visually impaired patient?
ANSWER Call clients by name before entering the room, Introduce yourself, Remain
within the client's line of vision if they have partial loss, Provide specific information
about the location of items or areas of the building, Describe treatments/interventions
before initiating them and before touching the client, Inform the client of your exit from
the room, Gently inspect the client's garments and recommend changes if dirty or torn,
Provide a radio, television, CD player or other digital player if desired, Describe the
location of food on the tray before exiting the room
List the elements of PQRST-ANSWER P: PROVOCATION: what makes it better or worse?
Q: Quality: describe the pain
R: RADIATION: does your pain radiate?
S: SEVERITY: on a scale of 1-10 how bad is the pain?
T: TIMING: when did it start? How long does it last?
How do you assess pain in an adult? -ANSWER ADULT: standardized pain scale images,
, words, numbers
How would you assess pain for a child? ANovu CHILD specialized pain scales (faces)
How would you care for a patient with a sensory deficit? The 5 senses-ANSWER
Significant stimulation, Large print material, electronic players for audiobooks, Amplify
phones, Pleasant aromas, Increase touch-back rubs, hand holding, ROM, hair care,
Vision and hearing assistive devices, Communicate often, Encourage family to bring in
flowers, pictures, pets, Objects that have texture, mental stimulation-crossword
puzzles, whistling, reciting
What are some of the non-verbal pain cues for a patient? ANSWER Grimacing, moaning,
flinching, guarding
Who are at risk for sensory deprivation? How do we care for these clients? - ANS Illness,
trauma, or isolation, Keep clients safe and free from injury, Make sure the call light is
easily accessible, Orient client to the room, Keep furniture clear from the path to the
bathroom, Keep personal items within reach, Place the bed in its lowest position, Make
sure IV poles, drainage tubes and bags are easy to maneuver
What is a discharge teaching relevant to a patient who is visually impaired? -ANSWER
Remove throw rugs to avoid tripping, Keep walking pathways clear, Ensure that
stairways are well lighted with secure handling, Use magnifying glass when reading,
Paint the edge of steps or build ramps instead of steps
Conductive hearing loss- ANSWER alteration in the middle ear that blocks sound waves
before they reach the cochlea of inner ear best in noisy environment
Sensorineural hearing loss- ANSWER alteration in the inner ear that blocks sound waves
before they reach the cochlea of inner ear
Mixed hearing loss- ANSWER combination of conductive and sensorineural hearing loss
What is the difference between delirium and dementia? - ANSWER Delirium is usually
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