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18 Cards in this Set

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A client with head and neck cancer has begun receiving radiation therapy to the right side of the neck. Because of the radiation treatments, the nurse includes the following intervention in the client’s plan of care:
A. NPO (nothing by mouth) during radiation therapy treatments
B. Mouth care every 4 hours with nondrying mouthwash
C. Lemon glycerin swabs to mouth every 2 hours
D. Gargle with Cepacol every 8 hours
B
The nurse working in a nursing home decides to implement a stringent mouth care protocol. The most important reason to established this protocol is because proper oral care:
A. Improves the client’s self-image
B. Can reduce the incidence of pneumonia in the elderly
C. Prevents the formation of caries
D. Minimizes the occurrence of halitosis
B
After performing a home assessment, the home care nurse makes the following safety recommendation to a family who will be caring for an older adult mother after discharge from the hospital:
A. Set the temperature of the water heater at a temperature that is not scalding.
B. Change all the water faucets so that the mother can easily turn them on and off.
C. Place a small throw rug in the bathroom to absorb water dripping off the body so that the mother will not fall.
D. Relocate the mother’s bedroom upstairs so that she is not bothered by activity of other family members.
A
The nurse understands that providing a complete bed bath may have the following cardiovascular effects and thus plans for rest periods during the bath:
A. Decreases blood supply to the skin
B. Decreases glucose demand
C. Increases oxygen supply
D. Increases oxygen consumption
D
Upon examining the feet of an older adult client with type 2 diabetes, the nurse notices long, thick nails. The client says that the nails catch on his socks and asks you to cut them. The most appropriate intervention the nurse implements is:
A. Soaking the feet in warm water before trimming the toenails
B. Providing toenail cutters to the client because nurses are not allowed to do this procedure
C. Calling the physician and asking for a foot care nurse consult
D. Instructing the unlicensed assistive personnel (UAP) to cut the toenails after the morning care
C
A client receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care interventions does the nurse recommend? (Select all that apply.)
A. Brush the teeth 2 to 3 times a day using a hard bristle brush.
B. Obtain an electric toothbrush to provide teeth cleaning.
C. Gargle with an alcohol-based mouthwash after each meal.
D. Gently floss between teeth once a day or more using unwaxed floss.
D
The nurse explains to a client with a new set of upper and lower dentures to care for them daily by doing the following. (Select all that apply.)
A. Remove at night.
B. Cover with water when not worn.
C. Store in an enclosed labeled cup.
D. Clean with weak bleach solution weekly
A,B,C
When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? (Select all that apply.)
A. Use fluorescent lamps.
B. Compare one side of the body with the other.
C. Look for grayish, eggplant-colored areas.
D. Use the back of a gloved hand to feel for skin temperature.
B,C
Hygienic care requires close contact with the client the nurse initially uses which of the following to protect a caring therapeutic relationship
1. communication skills
2. therapeutic skills
3. assessment skills
4. fundamental skills
1. communication skills
A clients personal preferences for hygiene are influenced by a number of factors. The nurse must recognize:
1. no two individuals perform hygiene in the same manner
2. the nurse is in charge of the care
3. Hygiene care is a routine procedure
4. Hygiene has no influence on client outcomes
1. No two individuals perform hygiene in the same manner
A person's body image is which of these concepts of his or her physical appearance.
1. subjective
2. objective
3. social
4. developmental
1. subjective
The healthy people 2010 initiative recommendations to improve:
1. American diet adding more carbohydrates
2. dental health
3. medication management in the elderly
4. skin care in the elderly
2. dental health
Clients most in need of perineal care are those at greatest risk of:
1. Acquiring an infection
2. death
3. needing to be institutionalized
4. falling
1. acquiring an infection
In addition to bathing, the following intervention may best promote client comfort
1. back rub
2. books on tape
3. snacks
4. postural drainage
1. back rub
Clients will experience conditions that threaten the integrity of oral mucosa; therefore:
1. less oral hygiene is needed
2. more frequent mouth care is needed
3. no mouth care should be performed
4. No antiinfective agents should be used
2. more frequent mouth care is needed
The priority when providing oral hygiene to an unconscious client is to
1. prevent aspiration
2. prevent mouth odor
3. prevent dental caries
4. prevent mouth ulcerations
1. prevent aspirations
Depending on the clients age and physical condition, the room temperature should be maintained between:
1. 68 and 74 degrees
2. 74 and 77 degrees
3. 78 and 80 degrees
4. 65 and 70 degrees
1. 68 and 74 degrees
The method for trimming nails is to
1. cut the nail in a curve
2. file the nail straight across
3. call a foot specialist
4. cut the nails to the cuticles
1. cut the nail in a curve