The nurse is reviewing assigned clients for morning care needs. ...

[misspop]

The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one client's personal hygiene?
 
  1. A client has a newly formed ileostomy.
  2. A client performs meticulous foot care.
  3. A German client refuses to bathe everyday.
  4. The room temperature is set at 72F.

Question 2

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client?
 
  1. The client will be able to name the staff that works on the day shift.
  2. The client will eliminate safety hazards in her environment.
  3. The client, with supervision, will brush her teeth.
  4. The nurse will stress the importance of adequate fluid intake.

[polinasid]

Answer to Question 1

Correct Answer: 1
Rationale 1: Some of the factors that influence one's personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change, which can greatly influence whether he will care for it or rely on others. This can pose a threat if the client chooses not to care for it.
Rationale 2: Performing meticulous foot care does not pose a threat to one's hygiene.
Rationale 3: Bathing every other day does not pose a threat to one's hygiene.
Rationale 4: Room temperature of 72F does not pose a threat to one's hygiene.

Answer to Question 2

Correct Answer: 3
Rationale 1: Cognitive impairment limits the client's ability to understand and comprehend; therefore, naming the staff is not within the client's realm of understanding.
Rationale 2: Cognitive impairment limits the client's ability to understand and comprehend; therefore, eliminating safety hazards is not within the client's realm of understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush her teeth without prompting from the staff.
Rationale 4: Cognitive impairment limits the client's ability to understand and comprehend; therefore, stressing adequate fluid intake is not within the client's realm of understanding.

[misspop]

Excellent

[mohan]

Gracias!