Nokea
An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct?
- A. When providing perineal care, washing the area from front to back
- B. Insisting the older adult must take a bath or shower each day
- C. Telling the patient to avoid soaking feet, helps the patient dry between the toes
- D. Covering areas not being bathed with a bath blanket
Correct Answer: B
Rationale: Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.
You may also like to solve these questions
When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply.
- A. Comparing bilateral parts for symmetry
- B. Proceeding in a toe-to-head, systematic manner
- C. Using standard terminology to communicate and document findings
- D. Avoiding using data from the nursing history to direct the assessment
- E. Documenting only skin abnormalities on the health record
- F. When risk factors are identified, following up with a related skin assessment
Correct Answer: A,C,F
Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.
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 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.
A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is 'itchy.' Which intervention is appropriate?
- A. Bathe the patient more frequently.
- B. Use an emollient on the dry skin.
- C. Explain that this is expected as people age.
- D. Limit the patient's fluid intake.
Correct Answer: B
Rationale: An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.
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.