Author Question: The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as ... (Read 72 times)

asd123 · **on:** Jul 23, 2018

The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as expected?

1. Dry, dark, thin
2. Smooth, taut, shiny
3. Smooth texture and not oily or dry
4. Tender, warm scalp

Question 2

The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should take priority?

1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath.

Gabe · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool.
Rationale 2: Skin is assessed as being smooth, taut, or shiny, not hair.
Rationale 3: The hair should be smooth in texture and neither oily nor dry.
Rationale 4: A tender, warm scalp could indicate a problem, so this would not be normal.

Answer to Question 2

Correct Answer: 3
Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow's hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctor's order.