A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?
Encourage the client to bathe frequently.
Apply powder to the client's skin.
Add moisturizing oil to the client's bath water.
Place a humidifier in the client's room.
The Correct Answer is D
Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.
Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"Sounds are soft and at a rate of 1/min" - This describes hypoactive bowel sounds, which are characterized by decreased motility, not hyperactive bowel sounds.
Choice B Reason:
"Indicates decreased motility" - This is a correct statement about hypoactive bowel sounds, not hyperactive bowel sounds.
Choice C Reason:
Sounds are high-pitched. Hyperactive bowel sounds are characterized by sounds that are loud and high-pitched. These sounds are often more frequent and rapid than normal bowel sounds, indicating increased motility of the gastrointestinal tract. Hyperactive bowel sounds can be associated with conditions like diarrhea or early bowel obstruction and are the opposite of hypoactive bowel sounds, which are soft and indicate decreased motility. Paralytic ileus, on the other hand, is a condition that can lead to hypoactive or absent bowel sounds.
Choice D Reason:
"Can be a result of a paralytic ileus" - Paralytic ileus typically results in hypoactive or absent bowel sounds, not hyperactive bowel sounds.
Correct Answer is B
Explanation
Choice A Reason:
A. Changing the appliance on a new colostomy requires specialized knowledge of ostomy care and assessment, including assessing stoma health and proper technique.
Choice B Reason:
This is an appropriate task to delegate to an AP. APs are trained to perform basic tasks like catheter care under the supervision of a nurse.
Choice C Reason
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient's ability to perform the procedure correctly, which requires clinical judgment and teaching skills and should not be delegated to an AP.
Choice D Reason:
This task involves assessing the wound, which requires clinical judgment and should be done by a nurse, not an AP.
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