Which action is appropriate when performing perineal care for an incontinent patient?

Correct Answer: C

Rationale: Patting the area dry after cleaning during perineal care prevents moisture-related irritation and skin breakdown, common in incontinent patients. Harsh soaps can strip natural oils, causing dryness or infection, so mild cleansers are better. Wiping back to front risks introducing fecal bacteria to the urethra, increasing UTI chances, especially in females front-to-back is the standard. Limiting care to once a week neglects hygiene needs, as incontinence requires frequent cleaning to avoid rashes or infections. Gentle drying maintains skin integrity, reducing friction and promoting comfort, which is critical for patients unable to manage their own hygiene.

Correct Answer: D

Rationale: Passive range-of-motion exercises, where the nurse moves the patient's limbs, maintain joint mobility and prevent contractures in bedridden patients unable to move themselves. This preserves flexibility and circulation, staving off stiffness and deformity from disuse. Independence isn't the immediate goal assistance is required. Assessing strength might occur incidentally, but it's not the purpose; active exercises test that. Exercise for staff is a byproduct, not the intent it's patient-focused. Nurses perform this to counteract immobility's effects, ensuring long-term joint health and comfort in dependent care scenarios.

Correct Answer: C

Rationale: A cooling blanket reduces a febrile patient's body temperature by transferring heat away from the skin, countering fever's effects and preventing complications like seizures. Inducing shivering raises temperature opposite of the goal and wastes energy. Providing warmth worsens fever, delaying recovery. Sweating might occur but isn't the aim; toxin elimination is a misconception cooling targets thermoregulation. Nurses use this to safely lower fever, monitoring closely to avoid overcooling, ensuring comfort and stability in hyperthermic states.

Correct Answer: D

Rationale: Ensuring the patient uses the walker as a weight-bearing aid promotes safety by providing stable support, distributing weight to reduce fall risk during ambulation. Pushing the walker from behind destabilizes it, removing patient control. Lifting it with each step negates its purpose continuous contact is key. Leaning forward risks tipping or losing balance. Nurses guide patients to grip firmly and step within the walker's frame, enhancing stability and confidence, a practical approach to safe mobility assistance.

Correct Answer: C

Rationale: Facing the patient and speaking clearly at a moderate volume enhances communication with a hearing-impaired patient by aiding lip-reading and ensuring audible clarity without distortion. Shouting distorts sound and facial cues, reducing effectiveness. Covering ears blocks sound entirely counterproductive. Medical jargon confuses; simple language works best. Nurses position themselves visibly, use gestures if needed, and confirm understanding, tailoring interaction to the impairment for accurate, respectful care delivery.