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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Correct Answer is D

Explanation

A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.

A. Burnout and secondary traumatic stress B. Lateral violence and intrapersonal conflict C. Physical and mental exhaustion D. Short-term grief and single stressor

Correct Answer is A

Explanation

A. Compassion fatigue is characterized by burnout and secondary traumatic stress, which result from prolonged exposure to caring for patients in distress and trauma, leading to emotional exhaustion.
B. Lateral violence and intrapersonal conflict involve hostile behavior and internal personal issues, which do not define compassion fatigue.
C. While physical and mental exhaustion can occur with compassion fatigue, they are not the defining aspects without the context of prolonged trauma exposure.
D. Short-term grief and a single stressor do not capture the chronic nature of compassion fatigue, which builds over repeated exposure to others' suffering.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is D

Explanation

A nurse has compassion fatigue. What is the nurse experiencing?

Correct Answer is A

Explanation

The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step?

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

The nurse is giving an intramuscular (IM) injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?

A nurse assesses a patient's fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating?

A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

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

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?