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A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
- A. Shifting the focus of the interaction to the 'process of bathing'
- B. Washing the face and hair at the beginning of the bath
- C. Using music to soothe anxiety and agitation
- D. Avoiding towel baths or forms of bathing with which the patient is unfamiliar
Correct Answer: C
Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the 'task of bathing' to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing 'body sections' one day at a time, as well as dry shampoo or 'shower cap' shampoos, are additional options.
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A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply.
- A. Patient taking antibiotics for chronic bronchitis
- B. Patient with type 2 diabetes
- C. Patient who has obesity
- D. Patient who frequently bites their nails
- E. Patient with prostate cancer
- F. Patient who frequently washes their hands
Correct Answer: B,C,D,F
Rationale: Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.
A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene?
- A. When the patient had their most recent bath
- B. The patient's usual hygiene practices and preferences
- C. Where the bathing fits in the nurse's schedule
- D. The time that is convenient for the AP
Correct Answer: B
Rationale: The patient's preferences, practices, and rituals should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.
A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply.
- A. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
- B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
- C. For male and female patients, always proceed from the most contaminated area to the least contaminated area.
- D. For male and female patients, use a clean portion of the washcloth for each stroke.
- E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
- F. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.
Correct Answer: A,D,E
Rationale: Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.
A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes?
- A. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes
- B. Wiping the eye from the outer canthus toward the inner canthus
- C. Positioning the patient on the opposite side of the eye to be cleansed
- D. Cleansing the eye using a different section of the cloth for each stroke until clean
Correct Answer: D
Rationale: The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean.
A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
- A. Wash the skin twice a day with a mild cleanser and warm water.
- B. Use cosmetics liberally to cover blackheads.
- C. Apply emollients on the area.
- D. Squeeze blackheads as they appear.
- E. Keep hair off the face and wash hair daily.
- F. Avoid tanning booth exposure and use sunscreen.
Correct Answer: A,E,F
Rationale: Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.