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Which cues would be found in a patient with a nursing hypothesis of Impaired Health Maintenance?
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Which cues would be found in a patient with a nursing hypothesis of Impaired Health Maintenance?
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Which hypothesis would the nurse select for a patient with redness and swelling at the site where a mole was recently removed?
Which hypothesis would the nurse select for a patient with redness and swelling at the site where a mole was recently removed?
The nurse has selected the hypothesis of Pressure Ulcer/Injury for a patient because of cues identified on the patient’s sacrum. Which other sites would the nurse examine thoroughly?
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The nurse has selected the hypothesis of Pressure Ulcer/Injury for a patient because of cues identified on the patient’s sacrum. Which other sites would the nurse examine thoroughly? Select all that apply
A patient has a wound that makes bathing difficult. Which short-term goal would the nurse add to the plan of care after a discussion with the patient?
A patient has a wound that makes bathing difficult. Which short-term goal would the nurse add to the plan of care after a discussion with the patient?
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For which reason is it important for hygiene and personal care goals to be measurable?
For which reason is it important for hygiene and personal care goals to be measurable?
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Which statement is phrased as a desired outcome for a pediatric patient being treated for head lice?
Which statement is phrased as a desired outcome for a pediatric patient being treated for head lice?
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Which activities can be delegated to the unlicensed assistive personnel (UAP) for a patient unable to perform self-care activities?
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Which activities can be delegated to the unlicensed assistive personnel (UAP) for a patient unable to perform self-care activities?
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Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care?
Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care?
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A patient is recovering from leg surgery and is unable to stand for self-care. Which hypotheses would be selected for hygiene and self-care?
A patient is recovering from leg surgery and is unable to stand for self-care. Which hypotheses would be selected for hygiene and self-care?
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Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences?
Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences?
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Which questions will the nurse ask when formulating a measurable hygiene and personal care goal?
Which questions will the nurse ask when formulating a measurable hygiene and personal care goal?
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Which example shows a correctly stated hygiene and personal care long-term goal?
Which example shows a correctly stated hygiene and personal care long-term goal?
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A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing hypothesis would the nurse select?
A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing hypothesis would the nurse select?
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Which cues would be found in a patient with a nursing hypothesis of Activity Intolerance relating to hygiene?
Which cues would be found in a patient with a nursing hypothesis of Activity Intolerance relating to hygiene?
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A nurse is training new staff to assess a patient’s activities of daily living (ADLs). Which areas would the nurse advise the new staff to include in their assessment?
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A nurse is training new staff to assess a patient’s activities of daily living (ADLs). Which areas would the nurse advise the new staff to include in their assessment?
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During a patient’s hospitalization, the nurse notes that the patient is unable to perform basic self-care. Which action would the nurse take to prepare the patient for discharge?
During a patient’s hospitalization, the nurse notes that the patient is unable to perform basic self-care. Which action would the nurse take to prepare the patient for discharge?
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For which factors would the nurse assess while inspecting difficult-to-reach areas of the skin?
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For which factors would the nurse assess while inspecting difficult-to-reach areas of the skin?
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The nurse would give extra attention to assessing for infections on and around the nails in a patient with which condition?
The nurse would give extra attention to assessing for infections on and around the nails in a patient with which condition?
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Which skin conditions might be present if a patient is having an allergic reaction to something he or she touched?
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Which skin conditions might be present if a patient is having an allergic reaction to something he or she touched?
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Which areas are common sites for pressure injuries?
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Which areas are common sites for pressure injuries?
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Match the hair or nail condition to its cause.
Match the hair or nail condition to its cause.
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When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?
When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?
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Which piece of clothing would the nurse remove when looking for excoriations?
Which piece of clothing would the nurse remove when looking for excoriations?
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Which type of injury results in a puncture wound?
Which type of injury results in a puncture wound?
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A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?
A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?
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Which assessment findings are indicative of poor hygiene? Select all that apply
Which assessment findings are indicative of poor hygiene? Select all that apply
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The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)? Select all that apply
The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)? Select all that apply
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An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient’s skin for which signs of infection? Select all that apply
An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient’s skin for which signs of infection? Select all that apply
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An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital?
An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital?
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Which factors are potential causes of halitosis? Select all that apply
Which factors are potential causes of halitosis? Select all that apply
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Study Notes
Impaired Health Maintenance
- Cues may include lack of adherence to dietary or medication regimens and inability to perform daily activities.
- Potential social or environmental barriers impacting health behaviors should be considered.
Redness and Swelling Post-Mole Removal
- Hypothesis of infection or delayed healing would be selected based on these signs at the surgical site.
Sites to Examine for Pressure Ulcer
- Thorough assessment of the heels, elbows, shoulders, and back of the head is essential.
Wound Care and Short-term Goal
- A goal for the patient's care plan may include promoting independence in self-care activities as recovery progresses.
Importance of Measurable Goals
- Measurable goals ensure objective evaluation of progress towards hygiene and personal care standards.
Desired Outcome for Pediatric Head Lice Treatment
- A specified outcome could be the complete elimination of lice and nits as confirmed by subsequent inspections.
Delegation to Unlicensed Assistive Personnel (UAP)
- Activities that can be delegated include bathing, grooming, and assisting with toileting.
Collaborative Approach to Self-Hygiene
- Involving the patient in their personal care plan enhances their commitment and efficacy in self-hygiene practices.
Hypotheses for Post-Surgery Hygiene Needs
- Hypotheses might include Activity Intolerance or Impaired Physical Mobility given the inability to stand for self-care.
Addressing Cultural Preferences for Hygiene Care
- The nurse should respect the patient's request by facilitating arrangements for a same-gender caregiver.
Questions for Measurable Hygiene Goals
- Questions could include: "How often do you want assistance?" or "What specific areas do you need help with?"
Stated Long-term Hygiene Goals
- An example may be maintaining skin integrity through daily care routines over the next month.
Nursing Hypothesis for Poor Grooming
- Hypothesis of Impaired Skin Integrity may apply given matted hair and debris under nails.
Cues for Activity Intolerance Related to Hygiene
- Signs may include difficulty completing tasks, unusual fatigue during bathing, or requiring assistance repeatedly.
Assessing Activities of Daily Living (ADLs)
- Key areas to assess include bathing, dressing, toileting, feeding, and mobility.
Preparing for Discharge with Self-Care Challenges
- The nurse should develop a discharge plan that includes community resources or assistance for ongoing care needs.
Factors Affecting Skin Assessment
- Factors to consider include skin moisture levels, mobility status, and any underlying health conditions.
Infection Risk in Nail Areas
- Patients with diabetes or peripheral vascular disease require careful assessment for infections around nails.
Allergic Reaction Skin Conditions
- Conditions may include hives, contact dermatitis, or localized swelling indicating an allergic response.
Common Sites for Pressure Injuries
- Common locations include the sacrum, heels, elbows, and back of the head.
Matching Hair/Nail Conditions to Causes
- Conditions like fungal infections may cause nail discoloration, while poor hygiene can lead to greasy or matted hair.
Assessing Pressure Injury Documentation
- Expect to find localized redness, warmth, and possibly drainage in the documented area.
Clothing and Skin Inspection
- Remove clothing from areas such as the lower back and buttocks to inspect for excoriations.
Puncture Wound Definition
- A puncture wound typically occurs from a sharp object piercing through the skin.
Immediate Calls to Healthcare Provider
- Findings like sudden changes in vital signs or high fever post-admission warrant immediate communication.
Indicators of Poor Hygiene
- Signs include strong body odor, unkempt appearance, and visible dirt or debris on skin or clothing.
Assessing Self-Care Capabilities in Acute Pancreatitis
- Questions to ask could focus on their ability to perform tasks independently and their level of fatigue.
Observing for Infection Signs in Pressure Injuries
- Signs may include increased redness, warmth, swelling, pus formation, or pain at the pressure injury site.
Discharge Planning for Older Adults with Limited Mobility
- Ensure adaptive devices and home modifications are arranged to assist with daily living activities post-discharge.
Causes of Halitosis
- Potential causes include poor oral hygiene, dental issues, and certain medical diseases affecting breath odor.
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Description
This quiz focuses on identifying cues associated with the nursing hypothesis of Impaired Health Maintenance. You will learn to select the relevant indicators that may reflect a patient's ability to maintain their health effectively.
