You ask J.F. whether she is ready for her bath and she responds positively. you let her bathe the parts shecan reach and engage her in a conversation as you attend to the rest of her body
While performing perineal care, you notice that the folds of skin around her perineal area are reddened and excoriated.
What is the likely cause of the problem and what needs to be done to encourage healing?
• The most likely cause is a superinfection caused by Candida organisms.
• Wash the area with soap and water. Dry thoroughly and allow maximal exposure to the air.
Separate opposing skin surfaces by placing a clean, dry washcloth or gauze pad between the skin
surfaces.
• Institute skin care protocol or inform the wound or skin care specialist, if available, and the
physician; follow prescribed treatment.
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The goal of treatment of the infant with phenylketonuria (PKU) is to
a. Cure mental retardation. b. Prevent central nervous system (CNS) damage, which leads to mental retardation. c. Prevent gastrointestinal symptoms. d. Cure the urinary tract infection.
A nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. What response to this assessment should the nurse expect to elicit?
A. Bilateral hypoactive reflexes of the knees and Achilles tendons B. Bilateral hyperactive reflexes of the knees C. Asymmetric reflex response D. Bilateral ankle clonus
Nursing interventions for the child after a cardiac catheterization include which of the following (Select all that apply)?
a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge.
The nurse manager in a hospital with a large immigrant population is planning an in-service. The nurse manager is aware of how ethnocentrism affects nursing care. Which statement should the nurse manager include?
"The belief that one's own values and beliefs are the only or the best values: 1. "Means that newcomers to the United States should adopt U.S. norms and values." 2. "Can create barriers to communication through misunderstanding." 3. "Leads to an expectation that patients will exhibit pain the same way." 4. "Improves the quality of care provided to culturally diverse patient bases."