Which outcome is desirable for a pediatric patient being treated for head lice?
Child refrains from sharing personal items with school classmates.
This is a desired outcome, meaning the goal of teaching the child not to share personal items is being met. The child is refraining from sharing personal items at school.
Which factors should the nurse consider when developing an individualized care plan for a patient's hygienic and self-care needs?
Present capabilities
The patient's present capabilities will help the nurse determine how much the patient can do to assist with personal care and hygiene.
Supportive resources
Supportive resources, such as family members or friends, when available, can help the nurse plan collaborative care when needed.
Family involvement
Family involvement must be assessed to determine
the extent to which family members desire to assist with the patient's personal care.
Personal care supplies
Personal care supplies are needed, such as soap and lotion, to adequately provide personal hygienic care.
Which activity does the nurse perform when planning for a patient's hygiene and personal care?
Prioritizes patient's hygiene-related nursing diagnoses
Nursing diagnoses are prioritized during the planning phase, so that top priority hygiene and personal care diagnoses can be addressed first.
Sets realistic personal care goals with the patient
The nurse does set realistic personal care goals with the patient during the planning phase of the nursing process.
Which hygiene and personal care nursing diagnosis is correctly stated?
Ineffective Health Maintenance related to impaired ability to understand due to brain injury, as evidenced by poor hygiene and unkempt appearance.
This hygiene and personal care diagnosis includes all three parts and is stated correctly.
Incorrect
Nursing diagnoses related to hygiene and personal care are selected after which important activity?
Assessing patient self-care abilities
Nursing diagnoses are selected after data has been collected through assessing the patient's self-care abilities.
A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing diagnosis will the nurse select?
Hygiene Self-Care Deficit
The data provided supports the selection of hygiene self-care diagnosis for this patient.
A patient is unable to perform self-care activities. Following collaboration with the UAP, which activities can be delegated?
Personal grooming
Personal grooming, such as hair combing, can be delegated to the UAP.
Partial bathA partial bath can be delegated to the UAP following initial assessment by the nurse.
Any specific problems that are noted during the bath, such as painful movement, should be reported to the nurse immediately.
Denture care
Denture care can be delegated to the UAP, as it is within the UAP's scope of practice.
Hair care
Because it is within the UAP's scope of practice, hair care can be delegated to the UAP.
Following collaboration about a patient's hygiene needs, which activities can be delegated to the UAP?
Applying lotion after bathing the patient
Applying lotion after bathing a patient can be delegated to a UAP, as it is within the UAP's scope of practice.
Assisting the patient with oral hygiene
Assisting the patient with oral hygiene is within the UAP's scope of practice, and can be delegated to a UAP.
Helping a patient shave prior to discharge
Helping a patient shave can be delegated to a UAP, as it is within the UAP's scope of practice.
The nurse delegated several patient tasks to UAPs on a nursing unit. Who is ultimately responsible for delegated tasks?
Delegating nurse
The nurse can assign and delegate tasks to UAPs based on their skill, knowledge level, and scope of practice, but the delegating nurse remains ultimately responsible for delegated tasks.
Why is it important to set measurable hygiene and personal care goals for patients?
Provides a means for measuring patient self-care progress.
Patient goals must be measurable because goals provide the means by which self-care progress is measured or determined. It they are not measurable, it cannot be determined if goals have been met.
Which is a correctly stated hygiene and personal care long-term goal statement?
Patient will shower independently by the end of one month.
This goal is a long-term goal because it will take a month to achieve the goal, rather
than a few days or a week. It is stated correctly.
Which questions will the nurse ask when formulating a measurable hygiene and personal care goal?
who, what, when
What should the nurse do when a patient requests the same gender caregiver for hygiene and personal care, due to cultural preferences?
Accommodate the patient's wishes
Addressing the patient's wishes, and providing the same gender caregiver for hygiene and personal care facilitates patient care and enhances the patient's comfort.
When is it appropriate for family members to be involved in setting hygiene and personal care goals for patients who can communicate their own needs and desires?
When the patient requires assistance after discharge
When the patient requires assistance after discharge, the family will need to be involved in goal-setting, because they will be responsible for carrying out hygienic and personal care for the patient at home.
Which action by the nurse indicates a collaborative approach to improving a patient's ability to perform self-hygiene and personal care?
Partnering with the occupational therapist
Partnering with the occupational therapist is collaboration, because both healthcare team members work together to plan interventions for the common goal of improving the patient's ability to perform self-hygiene and personal care.
A patient is unable to perform self-care activities. Following collaboration with the UAP, which activities can be delegated?
Personal grooming
Personal grooming, such as hair combing, can be delegated to the UAP.
Partial bath
A partial bath can be delegated to the UAP following initial assessment by the nurse. Any specific problems that are noted during the bath, such as painful movement, should be reported to the nurse immediately.
Denture care
Denture care can be delegated to the UAP, as it is within the UAP's scope of practice.
Hair care
Because it is within the UAP's scope of practice, hair care can be delegated to the UAP.
What are the three parts of the nursing diagnosis?
Diagnostic label, related factors, and evidence statement