Chapter 19: Assisting with Hy- giene, Personal Care, Skin Care, and the Prevention of Pressure Ul- cers

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 per- son systemi- cally. c. loss of sensation caused by dam- age to the nerves in the area. d. loss of body flu- ids and an upset in the fluid and electrolyte bal- ance. ANS: B The skin (and intact mucous mem- brane) is the first line of defense against invasion by pathogens, and any cut or abrasion can be an entry site. Scar formation, nerve dam- age, and fluid/electrolyte distur- bance are likely only when there is a large or deep wound. DIF: Cognitive Level: Compre- hension REF: p. 296 OBJ: Theory #1 TOP: Skin Integrity KEY: Nursing Process Step: Assess- ment MSC: NCLEX: Physiological In- tegrity: 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 exer- tion in physical therapy. b. suggest the pa- tient 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 pre- vent 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: Applica- tion REF: p. 296 OBJ: Theory #1 TOP: Fluid Replacement KEY: Nursing Process Step: Assess- ment MSC: NCLEX: Physiological In- tegrity: 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.