NURS 112: NCLEX questions - Taylor Ch 31 With Complete Solutions

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? a) Older adults b) Adolescents c) Middle-aged a ...

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? a) Older adults b) Adolescents c) Middle-aged adults d) School-aged children b) Adolescents As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a person ages, bathing frequently decreases, and older people may not use deodorant due to excessive drying of the skin. Which patient is most likely to require hospitalization related to problems associated with the feet? a) A patient with diabetes insipidus b) A patient with osteoporosis c) A patient with asthma d) A patient with peripheral vascular disease d) A patient with peripheral vascular disease Foot problems, particularly common in people with diabetes mellitus and peripheral vascular disease, often require hospitalization. 00:52 01:15 A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition? a) Stomatitis b) Gingivitis c) Glossitis d) Periodontitis c) Glossitis Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa. A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of which of the following? a) Alopecia b) Pediculosis c) Ticks d) Flease b) Pediculosis Infestation with lice is called pediculosis and results in frequent scratching and marks on the scalp. Alopecia is the absence or loss of hair. Ticks and fleas can cause itching, but pediculosis is best described by this scenario. The nurse assists the patient to the bathroom sink to perform morning care. The nurse observes the patient wash his face, arms, abdomen, and legs. The nurse washes the patient's back and rectal area and applies soap to the back. The patient brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the patient's chart? a) Self-care b) Complete care c) Partial care d) As-needed care c) Partial care Morning care is categorized as self-care, partial care, or complete care. Patients identified as partial care most often receive morning care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach. Patients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. Patients identified as complete care require nursing assistance with all aspects of personal hygiene. In additional to scheduled care, the nurse will offer care as needed. Which of the following does the nurse recognize as the most important component of the oral care process is when providing oral care? a) Selection of toothpaste b) A thorough mechanical cleaning c) Use of a mouthwash or breath freshener d) Application of moisturizing ointment to the lips b) A thorough mechanical cleaning Following the steps for cleaning the mouth thoroughly is more important than the agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning of the oral cavity. During morning care, the nurse notices a glass-like appearance to the patient's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretions related to illness? a) Normal saline solution b) Hydrogen peroxide solution c) Boric acid solution d) Soap and water a) Normal saline solution Wear gloves and use water or normal saline and cotton balls or a clean washcloth or compress to clean the eyes. Boric acid, once popular for cleaning the eyes, is no longer recommended, and the nurse should never use hydrogen peroxide or soap and water to clean the eyes. Upon review of the patient's orders, the nurse notes that the patient was recently started on an anticoagulant. What is an appropriate consideration when assisting the patient with morning hygiene? a) Avoid massaging the patient's back with lotion. b) Do not allow the patient to shower. c) Provide the patient with an electric shaver. d) Provide the patient with a firm bristled toothbrush. c) Provide the patient with an electric shaver. Electric shavers are recommended when a patient is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the patient is more prone to bleeding and the firm bristles may lead to bleeding. The patient should be allowed to shower, unless there are other contraindications, and a back massage will provide an ideal time to perform a skin assessment for bruising or breakdown. The nurse and nursing aid are providing perineal care for an incontinent patient. What information is important for the nurse to consider when providing perineal care? a) Aggressively cleanse the perineal area with a washcloth or towel. b) Wash the perineal area frequently with soap and water. c) Apply moisture barriers to the skin of the perineal area. d) Provide excessive hydration to the skin of the perineal area. c) Apply moisture barriers to the skin of the perineal area. Care to the perineal area for an incontinent patient includes the use of moisture barriers, skin cleansers, and moisturizers and the avoidance of the use of soap or friction. Measures should be followed to reduce over-hydration because this will increase the risk for perineal damage and skin breakdown. Positioning the patient's bed for safety is an important nursing measure. Which of the following must the nurse assure before leaving the patient's room? a) The bed controls are in a locked position. b) The side rails are in the lowered position. c) The bed is in its highest position. d) The wheels or casters are locked. d) The wheels or casters are locked. To promote bed safety, the nurse will assure that the wheels or casters are locked, the side rails are raised, the bed controls are functioning, and the bed is in its lowest position. The nurse has completed an assessment of a patient's typical hygiene practices. How should the nurse best document the findings of this assessment in the patient's chart? a) "Patient's level of personal hygiene is acceptable and age-appropriate." b) "Patient prioritizes personal hygiene in her daily routines and is proactive with skin care." c) "Patient normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." d) "Patient bathes more often than necessary and consequently experiences dry skin." c) "Patient normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." When documenting the nursing history, it is best to be specific, clearly describing the patient's typical hygiene practices and any complaints. Judgments regarding cause and effect are likely premature in this context and may be inaccurate. Which of the following health problems is most clearly suggestive of a history of inadequate dental care? a) Cheilosis b) Periodontitis c) Dry oral mucosa d) Alopecia b) Periodontitis Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency while dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss. A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which of the following teaching points should the nurse prioritize when educating the parents of students who have lice and nits? a) The need to destroy all clothing and bedding that the child has used b) The fact that the health problem is self-limiting c) The importance of teaching their children adequate personal hygiene habits d) The importance of completely finishing the prescribed treatment. d) The importance of completely finishing the prescribed treatment. When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the patient will shampoo the hair once and not follow through with a second washing. Pediculosis requires treatment and is not self-limiting. It is not necessarily a reflection of inadequate hygiene and is not necessary to destroy the child's clothing and bedding.