Nursing Care: Client Mobility and Hygiene

<p>To remove debris that could cause tooth decay and bad breath odor. (C)</p> Signup and view all the answers

<p>Every hour. (D)</p> Signup and view all the answers

<p>Slide the client manually across a transfer board. (C)</p> Signup and view all the answers

<p>Before and after each meal, and in the evening. (A)</p> Signup and view all the answers

<p>Transferring an immobile client may require the use of specialized equipment, such as a transfer board or client lift. (C)</p> Signup and view all the answers

<p>Supine, Prone, Sims', Fowler's, Dorsal Lithotomy, Lateral (C)</p> Signup and view all the answers

<p>Increased risk of falls (D)</p> Signup and view all the answers

<p>Character, Onset, Location, Duration, Severity, Pattern, Associated Factors (B)</p> Signup and view all the answers

<p>Force joint movement if there is resistance (D)</p> Signup and view all the answers

<p>Isometric exercises (B)</p> Signup and view all the answers

<p>Frequency (D)</p> Signup and view all the answers

<p>The continuous contraction (shortening of the length) of the muscles that move the bones of the joint (B)</p> Signup and view all the answers

<p>To manage pain effectively (D)</p> Signup and view all the answers

<p>The client's prescribed level of activity (A)</p> Signup and view all the answers

<p>Antibiotics (D)</p> Signup and view all the answers

<p>To ensure the client's safety and comfort (D)</p> Signup and view all the answers

<p>On a regular schedule or at the onset of pain (C)</p> Signup and view all the answers

<p>Providing a back rub or massage (A)</p> Signup and view all the answers

<p>To reassure the client and promote cooperation (D)</p> Signup and view all the answers

<p>To promote relaxation and alleviate pain (D)</p> Signup and view all the answers

<p>The inability to move around freely (A)</p> Signup and view all the answers

<p>To prevent joint deformities (B)</p> Signup and view all the answers

<p>Increased appetite (A)</p> Signup and view all the answers

<p>Heavy respiration (A)</p> Signup and view all the answers

<p>Cheyne-Stokes respirations (C)</p> Signup and view all the answers

<p>Peripheral resistance (D)</p> Signup and view all the answers

<p>115-120 mmHg (A)</p> Signup and view all the answers

<p>To detect the Korotkoff sounds associated with blood pressure (C)</p> Signup and view all the answers

<p>Sphygmomanometry (D)</p> Signup and view all the answers

<p>Cuff too small/narrow (A)</p> Signup and view all the answers

<p>Using a cuff that is too wide (D)</p> Signup and view all the answers

<p>Orthostatic hypotension (D)</p> Signup and view all the answers

<p>All of the above (D)</p> Signup and view all the answers

<p>Axillary (A)</p> Signup and view all the answers

<p>For patients who are unconscious (B)</p> Signup and view all the answers

<p>It is the fastest and non-invasive method. (C)</p> Signup and view all the answers

<p>It can alter the temperature reading. (C)</p> Signup and view all the answers

<p>To prevent cross-contamination between patients. (B)</p> Signup and view all the answers

<p>Temporal artery temperature (B)</p> Signup and view all the answers

<p>Rectal &amp; Tympanic (A)</p> Signup and view all the answers

<p>Elastic roller bandage/all cotton elastic (ACE) bandage (D)</p> Signup and view all the answers

<p>To provide compression to promote venous return (B)</p> Signup and view all the answers

<p>The bandage is too tight (D)</p> Signup and view all the answers

<p>every 2 hours (D)</p> Signup and view all the answers

<p>Stretch-net bandage/Tube Gauze (D)</p> Signup and view all the answers

<p>To promote venous circulation and prevent blood clots (D)</p> Signup and view all the answers

<p>To assist the RN in making and recording observations (C)</p> Signup and view all the answers

<p>Indentation remains after pressing (B)</p> Signup and view all the answers

<p>Elastic roller bandage/all cotton elastic (ACE) bandage (D)</p> Signup and view all the answers

<p>To stimulate blood return to the heart and prevent blood from pooling (B)</p> Signup and view all the answers

Measures body temperature via the mouth, more accurate than axillary.

Highly accurate temperature measurement via the anus, used for unconscious patients.

Measures temperature under the armpit, least accurate method.

Uses ear canal to measure temperature via thermal radiation; quick method.

Measures temperature from the forehead using infrared technology; quick and non-invasive.

Always cover the thermometer's sensor with tissue for hygiene.

Do not measure temperature orally if patient is confused or uses mouth to breathe.

Rhythmic wave of higher-pressure blood from heartbeats felt in arteries.

The positioning of the body to maintain balance and efficiency during movement.

Health issues arising from prolonged inactivity, such as pressure ulcers or blood clots.

Lying on the back, also known as dorsal recumbent position.

Lying on the abdomen, face down.

Lying on the back with the head elevated, often used for eating or breathing.

The specific motion available at each joint, important for movement and flexibility.

Exercises performed by a nurse to move a client's joints when they can't do it themselves.

Self-directed exercises performed by the client, involving full movement of joints.

Shortening of muscles leading to joint deformities due to lack of movement.

Following specific orders and safety measures when helping clients to stand or walk.

A mnemonic to gather pain characteristics: character, onset, location, duration, severity, and associated factors.

Medications that relieve pain, used regularly for effectiveness.

Categories for measuring pain: mild, moderate, severe, and excruciating.

How long pain lasts: occasional, intermittent, spasmodic, or constant.

Compassionate actions by nurses to relieve pain, such as providing comfort and diversions.

Effects of unrelieved pain, including nausea, fatigue, and depression.

Medications not primarily for pain, but can help manage it as well.

Actions to promote relaxation and alleviate pain, such as clean bedding and soft music.

Difficulty breathing only when lying down.

Condition causing breathing difficulty due to bronchial spasms.

Breathing pattern: slow, fast, then stop, often near death.

Pressure from blood flow in arteries, influenced by heart output and vessel resistance.

Phase of the heartbeat when the heart muscle contracts, highest blood pressure.

Phase when the heart relaxes, lowest blood pressure.

Drop in blood pressure when changing positions, common in older adults.

Difference between systolic and diastolic blood pressure readings.

Device used to measure blood pressure using a cuff.

Mistakes that can lead to inaccurate blood pressure readings.

Assist a client to stand on their stronger leg while supporting them on the weaker side. Pivot them to the chair using the stronger arm.

Use a transfer board, lifting sheet, or client lift for safer and easier transfers of immobile clients.

A lifting sheet can be placed under the client to lift them instead of sliding across a transfer board when other options are unavailable.

Offer oral hygiene before/after meals, observe oral health, and encourage flossing to prevent decay and odor.

Perform frequent oral cleansing for clients who are unresponsive or mouth-breathing to prevent choking and dryness.

Eye care involves removing dried secretions and using moistening agents like eye drops as needed to prevent infections.

Tears protect eyes from infections and lubricate them, helping to wash away foreign particles.

Wash a client's external ears routinely during bed baths to maintain hygiene.

Supports limbs/joints, holds dressings, immobilizes limbs, and promotes venous return.

A stretchy bandage wrapped around limbs to support muscles and joints or hold dressings.

A stretchy gauze used in a long roll for wrapping and dressing support.

Stockings that cover the foot and legs to prevent blood clots and ensure circulation.

Devices providing alternating pressure to legs for better circulation.

Evaluation of an extremity's status encased in a bandage or cast.

Assessment focusing on color, motion, sensation, edema, and temperature.

Too tight bandages can constrict blood vessels and nerves, causing damage.

Different bandages serve various purposes like support, dressing, and circulation.

Wide, flat fabric used to support body parts or hold dressings in place.