Nokea
A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response?
- A. To help with pain management
- B. To provide comfort
- C. To communicate to patients through touch
- D. To energize patients, especially those with dementia
- E. To facilitate healing after back or spinal surgery
- F. To help increase circulation
Correct Answer: A,B,C,F
Rationale: The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.
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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.
A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next?
- A. Recommend a consultation with an oral surgeon.
- B. Communicate the condition to the health care team.
- C. Gently scrape the oral cavity with a tongue depressor.
- D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.
Correct Answer: D
Rationale: If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.
A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply.
- A. Bathing the feet thoroughly in a mild soap and tepid water solution
- B. Soaking the resident's feet in warm water and bath oil
- C. Drying the feet and area between the toes thoroughly
- D. Applying an alcohol rub for odor and dryness to the feet
- E. Applying an antifungal foot powder
- F. Cutting the toenails at the lateral corners when trimming the nail
Correct Answer: B,D,F
Rationale: The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.
A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed?
- A. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve
- B. Cutting the gown with scissors to allow arm movement
- C. Threading the bag and tubing through the gown sleeve, keeping the line intact
- D. Temporarily disconnecting the tubing from the IV container, threading it through the gown
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency.
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.