Chapter 19 Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Chapter 19  Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:
a.
scar formation at the injury site resulting from the healing process.
b.
infection with bacteria or viruses that may affect the person systemically.
c.
loss of sensation caused by damage to the nerves in the area.
d.
loss of body fluids and an upset in the fluid and electrolyte balance.

ANS: B
The skin (and intact mucous membrane) is the first line of defense against invasion by pathogens, and any cut or abrasion can be an entry site. Scar formation, nerve damage, and fluid/electrolyte disturbance are likely only when there is a large or deep wound.

DIF: Cognitive Level: Comprehension REF: p. 296 OBJ: Theory #1
TOP: Skin Integrity KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to:
a.
call his primary care provider about the amount of exertion in physical therapy.
b.
suggest the patient walks slowly in the hall to “cool down.”
c.
offer additional fluids to replace those lost through normal cooling.
d.
place a light cover over the patient to prevent his chilling.

ANS: C
Diaphoresis (sweating) is the body’s normal response to rid itself of heat. Drinking fluids to replace those lost prevents dehydration.

DIF: Cognitive Level: Application REF: p. 296 OBJ: Theory #1
TOP: Fluid Replacement KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the:
a.
patient will shower daily on an independent basis by the end of 1 month.
b.
nurse will give a tub bath or full bed bath daily.
c.
patient will shower or tub bathe with assistance twice a week.
d.
patient will tub bathe or shower with assistance daily.

ANS: C
Older adults have decreased sweat and sebaceous gland activity and do not need a full bath or shower daily. Their skin is thinner and it becomes drier and itchy with overly frequent bathing. Because of the patient’s unsteadiness, it is not safe to have him shower alone.

DIF: Cognitive Level: Application REF: p. 301 OBJ: Theory #6
TOP: Hygiene and Safety KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. In assessing the skin condition of an older adult patient, the nurse notes that, over the sacral area, there is a 2 cm × 3 cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:
a.
“Patient has stage II ulcer on sacrum. No blanching of perimeter.”
b.
“Reddened area over sacrum, skin open in center.”
c.
“Pressure ulcer on sacrum. Massaged with no improvement in color.”
d.
“2 cm × 3 cm reddened area on sacrum with open center. Does not blanch.”

ANS: D
Description of a pressure ulcer should be specific and give a visual picture of the area. Such documentation will be useful in calculating the Medicare reimbursement for the facility.

DIF: Cognitive Level: Application REF: p. 300
OBJ: Clinical Practice #2 TOP: Pressure Ulcers
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. When instructing a nursing assistant about hygiene needs of a frail older adult patient, the nurse correctly educates the nursing assistant to:
a.
“Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling.”
b.
“Put bath oil in the tub and use plenty of soap to really clean the patient’s skin while she is in the tub.”
c.
“Use brisk drying and an alcohol rub to close the patient’s pores and prevent heat loss after the bath.”
d.
“Completely dry the patient’s skin and apply a mild moisturizer.”

ANS: A
Older adults have drier, thinner skin and less subcutaneous fat. Therefore, warm, not hot, water is needed, and chilling should be avoided. The older adult should use less soap (to decrease dryness), and the use of oils in the water can be hazardous. Older adults should be patted, not rubbed, dry, and moisturizer should be applied to skin that is still damp.

DIF: Cognitive Level: Knowledge REF: p. 301 OBJ: Theory #6
TOP: Skin Care KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort