A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client?
- Totally dependent (+4)
- Moderately dependent (+3)
- Semidependent (+2)
- Independent (0)
- Answer: 3. Rationale: The client fits the descriptors for a semidependent functional level (see Table 33–2). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-3.
The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client?
1. Presence of pain
2. Condition of the skin
3. Gag reflex
4. Range of motion
- Answer: 3. Rationale: The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of the gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. All other answers are assessments more appropriate prior to bathing the client. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-4.
A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin?
1. Soak her feet frequently.
2. Use a nonperfumed lotion.
3. Apply foot powder.
4. Avoid knee-high elastic stockings.
- Answer: 2. Rationale: A lotion will help moisten the skin. Perfumed lotions contain alcohol, which is drying to the skin. Soaking the feet for a long time or frequently also causes dry skin (option 1). Applying foot powder is appropriate to prevent or control unpleasant foot odor (option 3). Elastic stockings may decrease circulation (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-15c.
The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client’s hearing aid?
1. Turn the hearing aid off.
2. Soak the hearing aid in soapy solution to clean it.
3. Turn the volume all the way up.
4. Remove the batteries.
- Answer: 1. Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. Option 3 is incorrect; make sure the volume is turned all the way down because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-15h.
The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client?
1. Open bed in low position
2. Occupied bed in low position
3. Closed bed in high position
4. Surgical bed in high position
- Answer: 4. Rationale: Both the placement of the linens for a surgical bed and placing the bed in a high position facilitate the client’s transfer from a stretcher into the bed. The linens for a closed bed are drawn up to the top of the bed and under the pillows (option 3). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-14.
The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply.
1. Cover the client as much as possible.
2. Sing or talk to the client.
3. Complete the bath as quickly as possible.
4. Be organized.
5. Expect the client to protest—finish quickly.
- Answer: 1, 2, and 4. Rationale: Moving quickly may agitate the client (option 3). Protesting, screaming, and crying are not normal. Stop the bath and approach again later (option 5). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-8.
The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP?
1. Uses a clean portion of the washcloth for each stroke
2. Wipes from the pubis to the rectum 3. Uses clean gloves
4. Does not retract the foreskin
- Answer: 4. Rationale: It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 33-1.
The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply.
1. Using a bottle during naps and bedtime can cause dental caries in a toddler.
2. Schedule a visit to the dentist when your child is ready to go to school.
3. It is important for parents to supervise a child’s brushing of their teeth.
4. Most older adults have dentures and don’t need to worry about oral care.
5. Older adults are at risk for periodontal disease.
- Answer: 1, 3, and 5. Rationale: The developmental level warrants supervision. If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler’s teeth. The first visit to the dentist should occur between the ages of 2 and 3 (option 2). More than 50% of older adults have their own teeth (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 33-4.
The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching?
1. “I am going to use a mirror to check my feet.”
2. “I enjoy walking barefoot around the house.”
3. “I will file my nails.”
4. “I will increase the time that I wear new shoes each day.”
- Answer: 2. Rationale: The client needs to avoid walking barefoot because that could cause injury that may result in an infection. Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased sensation. The client would be unaware of an injury. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 33-4.
The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position?
1. Fowler’s
2. Semi-Fowler’s
3. Trendelenburg
4. Reverse Trendelenburg
- Answer: 1. Rationale: Fowler’s is a semisitting position that should ease the client’s breathing. The head of the bed (HOB) in semi-Fowler’s is lower (option 2). The HOB is lowered in the Trendelenburg position (option 3). Although the HOB is raised in the reverse Trendelenburg position, it is a straight tilt and may not be as comfortable as Fowler’s (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 33-13.
