A nurse is completing an assessment of the patient. Which ...

[Collmarie]

A nurse is completing an assessment of the patient. Which principle is a priority?
 
  a. Foot care will always be important.
  b. Daily bathing will always be important.
  c. Hygiene needs will always be important.
  d. Critical thinking will always be important.

Question 2

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive.
 
  The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?
  a. Stand to the side of the patient's eye and observe the cornea.
  b. Conclude that the glasses were lost during the accident.
  c. Notify the ambulance personnel for missing glasses.
  d. Ask the patient where the glasses are.

[jojobee318]

Answer to Question 1

ANS: D
A patient's condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Apply the elements of critical thinking as you use the nursing process to meet patients' hygiene needs. Critical thinking will help you determine when foot care, daily bathing, and hygiene needs are important and when they are not.

Answer to Question 2

ANS: A
An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patient's eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time and cannot assume the glasses are missing. Asking the patient where the glasses are is inappropriate since the patient is unresponsive.