The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

All cultures value cleanliness with the same degree of importance.

Patients who appear unkempt place little importance on hygiene practices.

The patient’s illness may require teaching of new hygiene practices.

Personal preferences determine hygiene practices and are unchangeable.

Answer and Explanation

The Correct Answer is C

A. Cultural values regarding cleanliness vary, so it is inaccurate to assume uniform standards.
B. Judging the patient as placing "little importance" on hygiene due to appearance can lead to biases and does not consider the patient’s routine.
C. Diabetes may necessitate changes in hygiene practices, especially regarding foot care, to prevent complications. Education on optimal hygiene practices is essential for health management in diabetic patients.
D. While personal preferences influence hygiene, they can be adapted with appropriate education and guidance when necessary for health reasons.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.

A. Childhood obesity. B. Prolonged poverty. C. Family relocation. D. Loss of stamina.

Correct Answer is B

Explanation

A. Childhood obesity may indicate dietary and lifestyle issues but does not directly reflect sociocultural factors affecting developmental problems.
B. Prolonged poverty can significantly impact a child's development by limiting access to resources such as nutrition, education, and healthcare, thus signaling a potential developmental issue.
C. Family relocation can cause stress and adjustment challenges but is not as directly associated with long-term developmental problems as prolonged poverty.
D. Loss of stamina may be a physical issue but does not necessarily correlate with sociocultural factors that would indicate developmental concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Correct Answer is A

Explanation

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem?

Correct Answer is B

Explanation

A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct?

A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem?

A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.)

The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?