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

she has little physical strength and lies seemingly

motionless for hours. Her skin is wrinkled and

paper thin, and her arms are already bruised from

unsuccessful attempts at intravenous therapy. She

was dehydrated on admission since she had spent

almost 48 hours crumpled at the bottom of her

steps before being found by her neighbors,and

she was clearly in need of nutritional, fluid, and

electrolyte support. A long-time diabetic, Mrs. Chi-

jioke is now spiking a fever (39.0C, or 102.2F),

which concerns her nurse.

2.Nursing Process Worksheet

Health Problem: Risk for impaired skin integrity

Etiology:Immobility; effects of aging, dehydration,

and illness

Signs and Symptoms: Skin of her coccyx, heels, and

elbows is reddened—returns to normal color when

pressure is relieved; lies motionless on her back

when unattended; skin is wrinkled and thin;

elevated temperature (39C).

Expected Outcome: Whenever observed, the patient’s

skin will appear clean and intact (no redness,

blistering, indurations).

Nursing Interventions:

a.Reposition patient in correct alignment at least

every 1 to 2 hours and ensure protection of pres-

sure points where possible; examine skin for

signs of breakdown with each position change.

b.Massage pressure points and keep skin clean and

dry.

c. Keep bed linens dry and free of wrinkles.

d.Monitor high-risk factors: dehydration, effects of

illness.

Evaluative Statement: 10/6/11: Goal met—patient’s

skin is clean and intact and shows no signs of

breakdown. Continue prevention program.

—M. Wong, RN

3.Patient strengths: Concerned neighbors; until now

has been able to care for herself and keep herself in

good health

Personal strengths: Ability to recognize patients

at high risk for problems such as impaired skin

integrity; strong commitment to meeting the needs

of geriatric patients; experienced clinician

4.10/6/11: Patient remains on an every-2-hour posi-

tioning regimen. The protective heel and elbow

pads have resulted in intact skin in these areas—no

redness. The skin on her coccyx appears reddened

after she lies on her back, but the redness disappears

when the pressure is relieved. No constant redness,

edema, or induration. Skin remains dry; lotion

applied with each position change.—M. Wong, RN

CHAPTER 33

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

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

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

11.a 12.a 13.b 14.d 15.d

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.c, d, f

2.a, c, e

3.b, c, d

4.a, e, f

5.b, d, e

6.c, e, f

7.a, b, c

8.b, c, e

DEVELOPING YOUR KNOWLEDGE BASE

IDENTIFICATION

1. a.Fowler’s position
   b.Protective supine position
   c. Protective side-lying or lateral position
   d.Protective Sims’ position
   e.Protective prone position
   MATCHING EXERCISES
   1.e 2.c 3.f 4.b 5.a
   6.l 7.a 8.g 9.o 10.d
   11.k 12.b 13.n 14.c 15.m
   16.j 17.h 18.e 19.i 20.b
   21.e 22.f 23.a 24.i 25.c
   26.d 27.g
   CORRECT THE FALSE STATEMENTS
   1.False—irregular bones
   2.True
   3.True
   4.True
   5.False—Body mechanics
   6.True
   7.False—wider
   8.False—proprioceptor or kinesthetic
   9.False—basal ganglia
   10.True
   11.True
   12.True
   13.False—facing
   14.True
   15.False—slide, roll, push, or pull

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