Solutions - Chapter 33 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. 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
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1CTC. It is the fourth day following a female client's abdominal surgery. She is progressing well, is ambulating several times each day, has been providing for her own hygienic needs, and is planning on going home borrow. During your early morning assessment, you note that the client's hair is oily and matted and she has an unpleasant body odor. Her dentures in a container at the bedside are in need of cleaning. You heck her abdominal incision and verify that there is no drainage, redness or signs of infection. You inquire about her ability to take care of her own bath and personal needs, and offer to assist her with her bath. She replies that she had a bath yesterday, doesn’t feel that she needs another one today, and requests to omit her personal care for the day.
You are considering Self-Care Deficit: Bathing as an appropriate nursing diagnosis for the client. You review the defining characteristics and related factors and discover what?
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1TYK. 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?
1.  Totally dependent (+4)
2.  Moderately dependent (+3)
3.  Semidependent (+2)
4.  Independent (0)
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2TYK. 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?
1.  Totally dependent (+4)
2.  Moderately dependent (+3)
3.  Semidependent (+2)
4.  Independent (0)
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3CTC. It is the fourth day following a female client's abdominal surgery. She is progressing well, is ambulating several times each day, has been providing for her own hygienic needs, and is planning on going home borrow. During your early morning assessment, you note that the client's hair is oily and matted and she has an unpleasant body odor. Her dentures in a container at the bedside are in need of cleaning. You heck her abdominal incision and verify that there is no drainage, redness or signs of infection. You inquire about her ability to take care of her own bath and personal needs, and offer to assist her with her bath. She replies that she had a bath yesterday, doesn’t feel that she needs another one today, and requests to omit her personal care for the day.
Why is it important that you obtain the assessments you have already completed along with the above questions you asked?
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3TYK. 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.
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4CTC. It is the fourth day following a female client's abdominal surgery. She is progressing well, is ambulating several times each day, has been providing for her own hygienic needs, and is planning on going home borrow. During your early morning assessment, you note that the client's hair is oily and matted and she has an unpleasant body odor. Her dentures in a container at the bedside are in need of cleaning. You heck her abdominal incision and verify that there is no drainage, redness or signs of infection. You inquire about her ability to take care of her own bath and personal needs, and offer to assist her with her bath. She replies that she had a bath yesterday, doesn’t feel that she needs another one today, and requests to omit her personal care for the day.
What approaches might you use if you feel that the client does need her hair shampooed and needs to have her personal care attended to?
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4TYK. 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.
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5CTC. It is the fourth day following a female client's abdominal surgery. She is progressing well, is ambulating several times each day, has been providing for her own hygienic needs, and is planning on going home borrow. During your early morning assessment, you note that the client's hair is oily and matted and she has an unpleasant body odor. Her dentures in a container at the bedside are in need of cleaning. You heck her abdominal incision and verify that there is no drainage, redness or signs of infection. You inquire about her ability to take care of her own bath and personal needs, and offer to assist her with her bath. She replies that she had a bath yesterday, doesn’t feel that she needs another one today, and requests to omit her personal care for the day.
What advantages does performing baths and personal hygiene for clients offer to the nurse?
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5TYK. 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
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6TYK. 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.
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7TYK. 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
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8TYK. The nurse is planning a presentation on oral health at an inter- generational 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 brushim 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.
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9TYK. The nurse is discussing foot care with a client who was recent 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"
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