Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)
A patient who has an indwelling catheter
A patient with urinary and fecal incontinence
A patient with rectal and genital surgical dressings
A bariatric patient
A circumcised male who is ambulatory
Correct Answer : A,B,C,D
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.
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Correct Answer is ["A","C","D","E"]
Explanation
A. Prolonged stress can weaken the immune system, making patients more susceptible to infections.
B. Prolonged stress typically leads to increased blood pressure due to the body's stress response, rather than low blood pressure.
C. Chronic stress can contribute to the development of diabetes by affecting glucose metabolism and increasing insulin resistance.
D. Allostasis refers to the process of achieving stability through change; prolonged stress can disrupt allostatic balance and lead to health issues.
E. Prolonged stress has been linked to an increased risk of developing certain types of cancer due to its effects on immune function and hormonal balance.
Correct Answer is B
Explanation
A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.