Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

around with my medicines. One helps my ticker

and the others keep me from shaking so much.”

2.Nursing Process Worksheet

Health Problem: Self-care deficit: bathing/hygiene,

dressing/grooming

Etiology:Neuromuscular impairment secondary to

Parkinson’s disease, effects of aging

Signs and Symptoms: Inability to bathe and groom

self independently (disheveled appearance, stains

on clothing, unshaven, presence of body odor)

Expected Outcome: Within 2 weeks, patient will be

able to perform self-care grooming activities with

assistance of home healthcare aide.

Nursing Interventions:

a.Assess patient’s ability to care for self in home

setting.

b.Explore availability of home healthcare aide to

visit patient and assist with personal hygiene

activities on a regular basis.

c. Maintain safe environment.

d.Encourage patient’s independent activities.

e.Investigate need for any adaptive equipment.

Evaluative Statement: 3/28/11: Expected outcome

partially met. Home healthcare aide assisting

patient for several hours, 3 mornings/week.

Continue to evaluate patient’s ability to manage

treatment regimen and need for any adaptive

equipment.—M. Gomez, RN

3.Patient strengths: Has previously been able to care

for self, motivated to maintain independence, car-

ing family member able to visit on a regular basis

Personal strengths: Commitment to caring, experi-

enced home healthcare nurse, strong interpersonal

skills, good knowledge of gerontologic nursing

4.3/28/11: Revisited patient 2 weeks after initial

visit. Patient alert and oriented. Neat personal

appearance—clean shaven, absence of body odor,

hair shampooed and combed, wearing clean clothes.

Stated, “my girlfriends love me now.” Conforming to

medication schedule and participating in social activ-

ities. Continue periodic observations.—M. Gomez, RN

CHAPTER 32

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

1.b 2.d 3.a 4.c 5.d

6.c 7.b 8.d 9.d 10.a

11.b 12.c

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.a, b, e

2.b, c, f

3.a, d, e

4.c, d, e

5.a, b, c

6.b, c, d

DEVELOPING YOUR KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1.Intentional wounds

2.Exudate

3.Neutrophils, polymorphonuclear

4.Granulation

5.Fistula

6.Sterile 0.9% sodium chloride solution

7.Circular turn

8.Pressure ulcer

MATCHING EXERCISES

1.a 2.f 3.q 4.j 5.e

6.n 7.k 8.p 9.i 10.m

11.o 12.c 13.d 14.h 15.l

16.f 17.a 18.g 19.a 20.b

21.d 22.c 23.e 24.g 25.e

SHORT ANSWER

1. a.Protect the body
   b.Regulate body temperature
   c. Sense stimuli from the environment and trans-
   mit these sensations
   d.Excrete waste products
   e.Help maintain water and electrolyte balance
   f. Produce and absorb vitamin D


2. a.External pressure: Compresses blood vessels and
   causes friction
   b.Friction and shearing forces: Tear and injure
   blood vessels


3. a.Nutrition: Poorly nourished cells are easily
   damaged (e.g., vitamin C deficiency causes cap-
   illaries to become fragile, and poor circulation
   to the area results when they break).
   b.Hydration: Dehydration can interfere with cir-
   culation and subsequent cell nourishment.
   c. Moisture on the skin: Moisture associated with
   urinary incontinence increases the risk for skin
   damage more than chemical irritation from the
   ammonia in urine.
   d.Mental status: The more alert a patient is, the
   more likely it is that he/she will relieve pressure
   periodically and manage adequate skin hygiene.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

382 ANSWER KEY

7.a, e, f

8.b, c, e

9.c, d, e

10.a, d, e

11.b, c, f

Prioritization Question

1.

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