A nurse explains the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?

Bathing keeps mucous membranes soft and moist

Bathing maintains the body temperature

Bathing causes the skin to peel

Bathing reduces the possibility of infection

Answer and Explanation

The Correct Answer is D

A. Bathing keeps mucous membranes soft and moist: Keeping mucous membranes moist is more directly related to oral care and hydration; whole-body bathing doesn’t primarily target mucous membrane moisture.

B. Bathing maintains the body temperature: Warm bathing can transiently affect body temperature, but bathing is not mainly used to maintain core temperature and may risk chilling in older adults if not done carefully.

C. Bathing causes the skin to peel: Excessive or harsh bathing can dry the skin and cause flaking, so this is not a benefit and indicates improper technique or products.

D. Bathing reduces the possibility of infection: Bathing removes transient organisms, dirt, and oils from the skin, lowering microbial load and helping reduce the risk of skin infections and complications.

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Correct Answer is ["A","B","C","E","G","H","I"]

Explanation

A. Cool skin: Hypothermia causes decreased skin temperature and pallor/cold skin on exposure.

B. Bradycardia: As core temperature falls, cardiac conduction slows and bradycardia commonly develops.

C. Impaired muscle coordination: Hypothermia slows nerve conduction and muscle function, causing clumsiness and decreased coordination.

D. Flushed skin: Flushed, warm skin is associated with hyperthermia or vasodilation; hypothermia typically produces cool, pale or cyanotic skin.

E. Diminished pain sensation: Cold reduces nerve conduction and sensation, often causing numbness and decreased pain perception.

F. Tachycardia: Tachycardia is more typical in early/mild stress responses; at moderate hypothermia (≈92°F) bradycardia is expected rather than tachycardia.

G. Irregular heart rhythm: Hypothermia predisposes to arrhythmias (e.g., atrial fibrillation, other irregular rhythms).

H. Listlessness: Mental slowing, lethargy, and decreased responsiveness commonly occur with significant hypothermia.

I. Impaired cognition: Cognitive impairment, confusion, and slowed mentation are common as core temperature drops.

A. Stage I B. Stage ii C. Stage iii D. Stage iv

Correct Answer is A

Explanation

A. Stage I pressure injury is characterized by intact skin with a localized area of nonblanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. The patient in the prompt has intact skin on their heel with a nonblanchable reddish area, which fits this description perfectly.

B. STAGE II: A Stage II pressure injury involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red or pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Since the patient's skin is intact, Stage II is incorrect.

C. STAGE III: A Stage III pressure injury involves full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough and/or eschar may be present. This is a much more severe injury than what is described.

D. STAGE IV: A Stage IV pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This is the most severe stage and is clearly not what is pictured or described.

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A nurse explains the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?

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Naxlex Comprehensive Predictor Exams

A client presents to the emergency department following an extended period outside in colder temperatures. The client's rectal temperature is 92 degrees F. Based on this finding, what clinical manifestations would the nurse anticipate? Select all that apply:

Correct Answer is ["A","B","C","E","G","H","I"]

Explanation

While performing a skin assessment on a bedridden patient, you note a reddish area on the patient's left heel. The skin is intact. The area is nonblanchable. See the picture below. Based on your findings, you suspect this may be which of the following pressure injury?

Correct Answer is A

Explanation

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?

During a skin assessment, the nurse notes an elevated, raised border filled with pus on a client's lower back. This would be referred to as which of the following skin lesions:

The nurse is preparing to provide a bed bath to a client in a long-term care facility. The client states to the nurse, "I don't want a bath; I am going anywhere, so it doesn't matter.". Which of the following would be most appropriate for the nurse to do:

The nurse is educating a client following a wound debridement to increase which protein in their diet to aid in wound healing. The nurse should educate the client to consume which of the following foods: Select all that apply:

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A client's heart rate is noted to be 44 bpm. This is referred to as which of the following:

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