Questions and Answers
Which cues would be found in a patient with a nursing hypothesis of Impaired Health Maintenance?
Select all that apply.
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? 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?
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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?
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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?
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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?
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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?
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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?
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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?
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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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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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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 areas are common sites for pressure injuries?
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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?
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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?
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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?
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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
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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
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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?
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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.
