ch. 31 hand hygiene questions

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Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? "I know these spots are called senile lentigines and they are likely cancer." "These brown spots are senile lentigines and are common when you get older." "All of these spots are called seborrheic keratosis and they should be taken off." "Older people often have splotchy skin due to seborrheic keratoses."

"These brown spots are senile lentigines and are common when you get older."

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?

"Those are senile lentigines and are common in older adults."

"What are your expectations about bathing at this time?"

"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." "It is important to keep the room at a comfortable temperature for the client." "Always ask the client if anything is needed before you leave the room."

The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?

"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6."

"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained." Many children achieve daytime bowel and bladder control between age 2 and 3 years. They usually stay dry through the night by 4 years. but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.

A client expresses concern regarding the use of a bag bath. Which statement(s) by the nurse is appropriate? Select all that apply. `

- "The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." - "The bag bath will reduce the spread of bacteria since we are able to use separate cloths." - "Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."

Which action(s) does the nurse take to care for a client unable to care for dentures? Select all that apply.

- Clean the dentures with a mild commercial cleaning agent - Clean dentures with a soft toothbrush - Store dentures in water in a covered container - Keep dentures in a denture cup while carrying them to the sink - Remove upper dentures by rocking them forward

- Contact health care provider regarding diminished pedal pulses. - Contact a podiatrist.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select all that apply.

- Keep extra batteries on hand. - Do not get hair spray or other chemicals on the hearing aid. - Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.

- Use a tub/shower seat if balance problems are present. - Carefully monitor water temperature. - Provide the client a long-handled shower brush or attachment if experiencing limited mobility.

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response? -"Advertised remedies that promise a cure may be a scam." -"The medication your healthcare provider prescribed will cure psoriasis." -"This is great news; please let me know how this remedy works for you." -"I know you will feel much better after you have been cured of psoriasis."

-"Advertised remedies that promise a cure may be a scam."

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response? (Select all that apply.) -"I understand; flossing makes my gums bleed too." -"Flossing removes plaque and food debris that a toothbrush may miss." -"The chance of tooth and gum disease can be reduced by flossing." -"You can use flossing in place of brushing teeth." -"When flossing, be certain to choose waxed floss."

-"Flossing removes plaque and food debris that a toothbrush may miss." -"The chance of tooth and gum disease can be reduced by flossing."

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? -"Use your ungloved hands to remove an unconscious client's dentures." -"Clean dentures with hot water to eliminate bacteria." -"After brushing dentures, leave them out of the client's mouth overnight." -"Hold dentures over a plastic basin or towel when cleaning them."

-"Hold dentures over a plastic basin or towel when cleaning them."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding?

-"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene measures have no affect on skin."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? -"I use a washcloth to clean the auricles and cerumen when needed." -"I use cotton-tipped applicators daily to remove cerumen." -"I never use bobby pins or other sharp objects when cleaning cerumen." -"I clean my ear mold on my hearing aid daily before use."

-"I use cotton-tipped applicators daily to remove cerumen." Clients should be educated to not use cotton-tipped applicatosr because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? -"I will look for eggs on hairs ¼ to ½ inch from the scalp and skin surfaces." -"Lice can be spread by direct contact." -"I will use conditioner so that the lice eggs will slide off my hair." -"A pediculicide shampoo is needed to treat this condition."

-"I will use conditioner so that the lice eggs will slide off my hair."

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction? -"Brushing is important to remove bacteria from the mouth and teeth." -"Tartar cannot be brushed or flossed way." -"Flouride treatments are needed until my children reach the age of 14." -"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

-"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. -"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"It is important to include hair care and shampooing along with brushing in your hygiene routine." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Bathing regularly and applying lotion and cream as needed are important." -"Hygiene measures have no affect on skin."

-"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Hygiene measures have no affect on skin."

A client expresses concern regarding the use of a bag bath. Which statement by the nurse is most appropriate?

-"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." -"The bag bath will reduce the spread of bacteria since we are able to use separate cloths." -"Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? -"Older people often have splotchy skin due to seborrheic keratoses." -"I know these spots are called senile lentigines and they are likely cancer." -"All of these spots are called seborrheic keratosis and they should be taken off." -"These brown spots are senile lentigines and are common when you get older."

-"These brown spots are senile lentigines and are common when you get older."

-"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." -"Always ask the client if anything is needed before you leave the room." -"It is important to keep the room at a comfortable temperature for the client."

The health care environment can be very stressful for a client. During an orientation session of nursing students, the nursing instructor teaches students how to minimize a stressful environment. Which statement from the students indicates the teaching was effective? Select all that apply. -"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." -"We should discuss the client's condition outside of the room in order not to violate HIPAA." -"It is important to keep the room at a comfortable temperature for the client." -"Always ask the client if anything is needed before you leave the room." -"Spray the room daily with Lysol to reduce the spread of germs and maintain a sterile smell to assure the client it's clean."

-"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." -"It is important to keep the room at a comfortable temperature for the client." -"Always ask the client if anything is needed before you leave the room."

The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse? -"It is very uncommon for a child of this age to have bedwetting issues." -"Did any of your other children have this problem?" -"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6." -"You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening."

-"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6."

A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, "I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants." What is the best response the nurse can make? -"To help with potty training, the child should be placed on the toilet in the morning." -"The child should have fluids limited after 7 p.m. to help decrease the chance of nighttime bedwwetting." -"A child her age should have control of the bladder by now, but her bowels won't be trained until next year." -"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained."

-"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained."

The nurse is caring for four clients. For which client is a sitz bath most appropriate? -42-year old recovering from a C-section delivery -51-year old with hemorrhoids -60-year old who is 1-day post-op from a knee replacement -73-year old with pneumonia who can get up to bedside commode

-51-year old with hemorrhoids

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? -An infant's skin and mucous membranes are protected from infection by a natural immunity. -Secretions from skin glands are at their maximum from age 3 on. -The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. -An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

-An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. Adolescents have enlarged sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining to the mucous membranes. Secretions from skin glands occur later than age 3 months. While the skin may have more wrinkles as a person ages, the skin actually becomes thinner with age.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? -Assign a care provider who shares the same culture as the client. -Assess the skin every day using the Braden scale. -Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). -Assess the client's cultural views regarding hygiene and self-care.

-Assess the client's cultural views regarding hygiene and self-care.

A nurse is teaching a client with a burn injury regarding the function of the skin structure. Which teaching elements are appropriate to include when explaining risks for injury to the client? (Select all that apply.) -Because of the burn, the skin is not able to fully the protect the body from injury and infection. -It may be necessary to wear layers of clothing to keep warm, as the skin is what helps the body regulate body temperature. -Full exposure of the burned area to sunlight is very important to convert vitamin D. -Be sure to place the burned area into the tub water first to make sure the temperature of the water is acceptable. -Additional caloric intake may be needed to help maintain fluid and nutritional balance to foster healing of the burned area

-Because of the burn, the skin is not able to fully the protect the body from injury and infection. -It may be necessary to wear layers of clothing to keep warm, as the skin is what helps the body regulate body temperature. -Additional caloric intake may be needed to help maintain fluid and nutritional balance to foster healing of the burned area

Which is a recommended guideline when removing contact lenses from a client's eyes? -Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea. -Once removed, place both lenses in a cup and label it with the name of the client. -If an eye injury is present, remove lenses immediately to avoid causing additional injury. -If the contact lenses cannot be removed, they will have to be removed by the physician under sterile conditions.

-Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea.

The nurse is providing care to a client's eyes. What actions are appropriate when providing eye care? Select all that apply.

-Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cotton ball; or compress. -Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. -Use a different section for each stroke until the eye is clean

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met? -Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain. -Client recognizes the need for self-care and states he is able to perform independently. -Client is able to wash his upper extremities independently and needs assistance with his lower extremities. -Bath completed with no distress of discomfort noted.

-Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? -Clip the toenails with large clippers. -Contact a podiatrist to care for toenails. -Use a handheld electric rotary file to reduce length of toenails. -Clean under toenails with a wooden orange stick.

-Contact a podiatrist to care for toenails.

There are many problems that can occur on the feet that, if found, need to be assessed further. Which common foot problem is a cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint? -Callus -Corn -Plantar wart -Bunion

-Corn

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? -Remove ingrown toenails. -Cut the nail straight across. -Protect the foot from blisters. -Soak the foot in witch hazel.

-Cut the nail straight across.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select All That Apply

-Do not get hair spray or other chemicals on the hearing aid. -Keep extra batteries on hand. -Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

Self-care refers to a person's ability to perform primary care functions- in four areas- without the help of others. Which is not one of these areas? -Bathing -Toileting -Feeding -Driving

-Driving

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? -Always proceed from the most contaminated area to the least contaminated area. -Do not retract the foreskin in an uncircumcised male. -Dry the cleaned areas and apply an emollient as indicated. -Powder the area to prevent the growth of bacteria.

-Dry the cleaned areas and apply an emollient as indicated.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention? -Explain that cleanliness helps to remove bacteria from skin, which can prevent infection. -Offer a choice of types of soap and shampoo. -Schedule bath in the morning or evening according to client's preferred bathing time. -Encourage client to help with self-hygiene as able.

-Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation? -Gently slide the hard lens over the cornea and remove it with gloved fingers. -Remove the contact from the area it is located using gloved fingers. -Remove the contact with a contact remover. -Do not attempt to remove the contact because this will cause damage to the cornea.

-Gently slide the hard lens over the cornea and remove it with gloved fingers.

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record? -Caries -Tartar -Gingivitis -Plaque

-Gingivitis

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings? -Complete bed bath -Partial care -Independent showering -The client should not be bathed

-Independent showering

-It may be necessary to wear layers of clothing to keep war, as the skin is what helps the body regulate body temperature. -Additional caloric intake may be needed to help maintain fluid and nutritional balance to foster healing of the burned area. -Because of the burn, the skin is not able to fully the protect the body from injury and infection.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.) -Keep extra batteries on hand. -Do not get hair spray or other chemicals on the hearing aid. -Store the hearing aid in a very warm environment so that it will not crack. -Use a small knife to remove cerumen that becomes embedded in the earpiece. -Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

-Keep extra batteries on hand.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point? -Gently squeeze the infected areas to release the infection. -Wash your face less frequently to avoid removing beneficial oils. -Keep hair off the face and wash hair daily. -Use cosmetics and emollients to cover the condition.

-Keep hair off the face and wash hair daily.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother? -Leave the baby's buttocks open to air for 2 hours each day. -Apply gentian violet to the buttocks with every diaper change. -Change diaper as soon as it is soiled and apply cornstarch. -Keep the diaper and buttocks clean and dry and apply zinc oxide.

-Keep the diaper and buttocks clean and dry and apply zinc oxide.

When caring for a client with dentures, what should the nurse teach the client? -Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit. -Dentures should be wrapped in tissue or a disposable wipe when out of the mouth and stored in a disposable cup. -Dentures should never be stored in water because the plastic material may warp. -A brush and nonabrasive powder should be used to clean the dentures, and hot water should be used to rinse them.

-Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide? -Lesions should be squeezed gently to release pus. -Launder gowns, linens, and towels separate from other clients items. -There would be no intervention, as this chronic skin disorder is noninfectious. -Apply cortisone to this reddened rash.

-Launder gowns, linens, and towels separate from other clients items. Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal? -Normal saline -Sterile water -Hypertonic solution -Hypotonic solution

-Normal saline

A nurse has finished providing morning care for the client. What safety measures should the nurse employ prior to leaving the client's room?

-Place the call light near the client within reach. -Place the bed in the lowest position. -Test the functioning of the bed and bed controls. -Ensure the bed is locked.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task? -Apply pressure over the eye with your index finger and thumb under the eye. -Pull up the upper lid and place your index finger under the glass edge. -Pull the inner canthus toward the bridge of the nose and lift under the glass. -Pull down on the lower lid and exert slight pressure below the lid.

-Pull down on the lower lid and exert slight pressure below the lid.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? -R/t the inability to recognize the need to urinate or defecate -R/t right-sided weakness -R/t the inability to perform bathing independently -R/t impaired mobility

-R/t right-sided weakness

Which nursing action is appropriate when providing foot care for a client? -Soak the feet in a solution of mild soap and tepid water. -Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. -For diabetic clients, trim the nails with nail clippers. -Cut off any corns or calluses.

-Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

When performing health education regarding hygiene, the nurse should advise female clients to avoid the use of which products/activities? Select all that apply. -Routine douching -Vaginal deodorants -Tampons -Commercial soap -Unscented sanitary napkins

-Routine douching -Vaginal deodorants

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? -She has hot water to bathe in. -She has good mobility around her home. -She has motivation to participate in self-care. -She has family and friends who help her with self-care.

-She has motivation to participate in self-care.

A nurse is educating a client on how to care for their dentures. What is a recommended teaching guideline? -Remove dentures whenever possible to rest the gums. -Wrap dentures in a napkin when not using them. -Keep dentures near you in the bedding for easy access. -Store dentures in cold water when not in use.

-Store dentures in cold water when not in use.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? -Do not change batteries by yourself. -Clean the hearing aid with a bleach. -Store the hearing aid in cool environment. -Use sandpaper to clean off hardened cerumen residue.

-Store the hearing aid in cool environment.

The nurse is assisting a 56-year-old female who has undergone a mastectomy with her morning care. Which action by the client requires further teaching by the nurse? -The client applies deodorant. -The client provides care independently. -The clients applies cosmetics after her bath. -The client uses a bag bath.

-The client applies deodorant. Clients who have undergone surgery for a mastectomy should avoid the use of deodorants or antiperspirants postoperatively because they act to close sweat glands and can cause skin irritations.

-The client uses cool water for the treatment. -The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. -The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C).

The nurse has provided instruction to the client concerning the use of the sitz bath. After the instruction the nurse is evaluating the client's understanding of the education. Which findings indicate the need for further instruction? Select all that apply. -The client uses cool water for the treatment. -The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). -The client reports that the treatment will take approximately 20 minutes. -The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. -The client reports the treatment will promote circulation to the problem area.

-The client uses cool water for the treatment. -The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). -The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? -Obtain a tub or shower seat if the client has mobility issues. -Use bath oil in the tub to decrease dry skin. -Grab bars should be placed in the shower or tub at arm level. -Soap should be used sparingly so the client's skin does not become overly dry.

-Use bath oil in the tub to decrease dry skin.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? -Take aspirin for headaches that develop. -Use electric razor for shaving purposes. -Buy hard-bristle toothbrush to ensure proper oral hygiene. -Reassure client that prolonged bleeding of wounds and gums is normal.

-Use electric razor for shaving purposes.

-Use of a tub/shower seat may be necessary if balance problems are present. -Water temperature should be monitored carefully due to decreased temperature sensation. -Use a long-handled shower brush or attachment to help with limited mobility.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply. -Use of a tub/shower seat may be necessary if balance problems are present. -Use vigorous rubbing motions when drying the skin to increase circulation. -Water temperature should be monitored carefully due to decreased temperature sensation. -Use a long-handled shower brush or attachment to help with limited mobility. -Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? -Obtain a tub or shower seat if the client has mobility issues. -Check bath water temperature before allowing client to bathe. -Grab bars should be placed in the shower or tub at arm level. -Use soap daily when bathing to remove debris and keep skin moist.

-Use soap daily when bathing to remove debris and keep skin moist.

Which modification to bathing should be implemented for a client who is incontinent? -Use special perineal skin cleaners and moisture barriers. -Use a topical antiseptic, such as povidone-iodine, in the perineal area. -Decrease the frequency of bathing to preserve skin integrity. -Perform a full bed bath each time the client has an episode of incontinence.

-Use special perineal skin cleaners and moisture barriers.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: -anxiety. -alopecia. -dandruff. -seborrhea.

-alopecia. Most commonly, hair loss (alopecia) is caused by cancer treatment.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to: -allow the client privacy. -assess the client's safety. -assess the client's pain. -allow sufficient time.

-assess the client's safety.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be: -client will participate in self-care measures by the end of the week. -client will recognize the need for self-care. -client will verbalize the need to use to use the bedpan by the end of shift. -client will consent to no hygiene measures.

-client will participate in self-care measures by the end of the week.

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: -braids should be undone every day. -combs should be washed as often as necessary. -hair should be washed as often as necessary. -lubricants or oils should not be used on the braids.

-hair should be washed as often as necessary.

An older adult client is reporting dry, itching skin. The nurse should assess: -how often the client is bathing. -when the client's last tub bath was. -what linens they are using. -when the severe itching occurs.

-how often the client is bathing.

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. Which condition may result from chemotherapy? -changes in skin color -excess hair growth -loss of hair -dry, brittle nails

-loss of hair

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? -medications listed on the client's medication administration record (MAR) -cultural views and attitudes toward facial hair and grooming -client's allergies to soap since shaving cream is contraindicated in the hospital -the last time shaving was performed because clients can only shave twice weekly in the hospital

-medications listed on the client's medication administration record (MAR)

A client is hospitalized with orthostatic hypotension from dehydration. A nurse must delegate the task of hygiene and morning care to an unlicensed assistive personnel (UAP). What type of bath should the nurse instruct the UAP to provide to the client? -complete bed bath -partial bath -independent showering -The client should not be bathed

-partial bath Even while hospitalized, independence is encouraged, so allowing the client to receive a partial bath with assistance is appropriate. The client is likely stable enough to allow hygiene measures.

A kindergarten student is sent to the school nurse because they have been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of: -pediculosis. -alopecia. -ticks. -fleas.

-pediculosis. Infestation with lice is called pediculosis and results in frequent scratching and marks on the scalp. Alopecia is the absence or loss of hair. Ticks and fleas can cause itching but they are common infections to animals and not humans.

The nurse has delegated oral care for an unconscious client to an unlicensed assistive personnel (UAP). Which UAP action requires immediate nursing intervention? -placing the client supine to perform mouth care -moistening oral swabs before inserting them into the mouth -mixing equal parts baking soda and table salt in warm water to be used to remove accumulated secretions -applying petroleum jelly to lips

-placing the client supine to perform mouth care

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? -washing the skin with soap and water prior to shaving -pulling the razor against the direction of hair growth -rinsing the razor after each stroke of the razor -applying direct pressure to an area that is bleeding

-pulling the razor against the direction of hair growth

A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client? -sitz bath -sit-down shower chair -bag bath -partial bath at a washbasin

-sitz bath

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits? -the importance of completely finishing the prescribed treatment -the importance of teaching their children adequate personal hygiene habits -the fact that the health problem is self-limiting -the need to destroy all clothing and bedding that the child has used

-the importance of completely finishing the prescribed treatment

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: -there is a need to determine if the bottled water has fluoride. -the preschool child should not drink bottled water. -the preschool child should only drink milk. -the parent should alternate bottle and tap water.

-there is a need to determine if the bottled water has fluoride.

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? -traditional bed bath with linen change -shower with assist -bag bath -tub bath

-traditional bed bath with linen change

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: -understand that his culture may influence his hygiene and ask him his preference. -ask another nurse to assist in giving the client a complete bath every other day. -give the client a bath pan and tell him she will return when he has finished. -Encourage the client to bathe daily as part of protection from infection.

-understand that his culture may influence his hygiene and ask him his preference.

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse? -using ungloved hands to remove an unconscious client's dentures -cleaning dentures with tepid water from the sink -encouraging the client to leave the dentures in their mouth overnight -holding dentures over a plastic basin or towel when cleaning them

-using ungloved hands to remove an unconscious client's dentures

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response

"Advertised remedies that promise a cure may be a scam."

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response?

"Advertised remedies that promise a cure may be a scam."

"Flossing removes plaque and food debris that a toothbrush may miss." "The chance of tooth and gum disease can be reduced by flossing."

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first? "Why don't you help wash your legs and feet?" "When would you rather take your bath: in the morning or evening?" "Would you prefer to use the lavender soap or the oatmeal soap to wash with?" "Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?

"Hold dentures over a plastic basin or towel when cleaning them."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. "Hygiene measures have no affect on skin." "Bathing regularly and applying lotion and cream as needed are important." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "It is important to include hair care and shampooing along with brushing in your hygiene routine." "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums."

"Hygiene measures have no affect on skin." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums."

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?

"I am placing the new linens under the rolled, soiled lines to avoid contamination."

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction?

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use." "I use a washcloth to clean the auricles and cerumen when needed."

"I use cotton-tipped applicators daily to remove cerumen."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?

"I use cotton-tipped applicators daily to remove cerumen." To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicatosr because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

The nurse is caring for a client that has multiple dental caries and wants to understand the cause. Which statement by the client indicates that additional teaching is warranted?

"I will brush once every day and floss every other day."

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? (Select all that apply.)

"I will rinse with water when I cannot brush." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice." The client should brush teeth twice daily, rinse with water when brushing cannot be accomplished, avoid soda of any kind, increase calcium intake, and refrain from chewing ice.

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? Select all that apply

"I will rinse with water when I cannot brush." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice."

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response? "You will need to sit up for your bath, and then I will change your bed." "You will be able to take your bath by yourself tomorrow when you can get up." "I will set up your bath for you. I will come back and help you with your bath." "I really have limited time. Let me give you your bath right now."

"I will set up your bath for you. I will come back and help you with your bath."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "A pediculicide shampoo is needed to treat this condition." "I will use conditioner so that the lice eggs will slide off my hair."

"I will use conditioner so that the lice eggs will slide off my hair."

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction?

"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

A parent reports that their home water is not fluoridated and questions the nurse whether it would be beneficial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?

"In the absence of fluoridated water supplies, supplementation is often recommended."

"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin."

The nurse is caring for an older adult client in a long term care facility that is incontinent of urine. The client is very upset about this loss of dignity and expressing anger to the nurse providing care. He states, "Get away from me. I can get to the restroom on my own. You don't know what I need." Which response would be the most therapeutic for the nurse to say?

"It sounds as if you are angry. Let's talk about it"

An 80-year-old man is in a skilled nursing facility. He has recently become incontinent of urine. He is very angry by this change and has been expressing this anger toward anyone who is helping to care for him. When a nurse walks in his room to perform an initial assessment, he states, "Get away from me. I can get to the restroom on my own. You don't know what I need." Which response would be the most therapeutic for the client in this situation?

"It sounds as if you are angry."

A client who has been reluctant to have his or her hair shampooed for a week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." The client's hair is very greasy, the scalp is irritated, and it has begun to smell. What is the appropriate nursing response?

"Let's talk about what might be bothering you about your hair."

A client who has been reluctant to have their hair shampooed for a week tells the nurse, "I don't want you to shampoo my hair. It doesn't need washing." The client's hair is very greasy, the scalp is irritated, and it has begun to smell. What is the appropriate nursing response?

"Let's talk about what might be bothering you about your hair."

A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate?

"Tell me about what you do to take care of your hair."

The acute care nurse is talking with an older client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact."

brushing teeth

45 degree angle

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes

Which client is most at risk for foot difficulties? 80-year-old man with coronary artery disease 45-year-old woman with type 2 diabetes 91-year-old man with renal insufficiency 34-year-old woman who is paraplegic

45-year-old woman with type 2 diabetes People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 73-year old with pneumonia who can get up to bedside commode 60-year old who is 1-day post-op from a knee replacement 42-year old recovering from a C-section delivery 51-year old with hemorrhoids

51-year old with hemorrhoids

*sitz bath

A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client? *sitz bath *sit-down shower chair *bag bath *partial bath at a wash basin

*"Those are senile lentigines and are common in older adults."

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? *"Older people often have splotchy skin due to seborrheic keratoses." *"Those spots are senile lentigines and may be cancerous." *"Those spots are benign and are known as seborrheic keratoses." *"Those are senile lentigines and are common in older adults."

*"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." *"The bag bath will reduce the spread of bacteria since we are able to use separate cloths." *"Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."

A client expresses concern regarding the use of a bag bath. Which statement(s) by the nurse is appropriate? Select all that apply. *"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." *"The bag bath will reduce the spread of bacteria since we are able to use separate cloths." *"We have to use a bag bath to save the nursing staff's time." *"Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied." *"The cloths from the bag bath promote friction and allow us to clean your skin better."

*Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met? *Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain. *Client recognizes the need for self-care and states he is able to perform independently. *Client is able to wash his upper extremities independently and needs assistance with his lower extremities. *Bath completed with no distress of discomfort noted.

*R/t right-sided weakness

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? *R/t the inability to recognize the need to urinate or defecate *R/t right-sided weakness *R/t the inability to perform bathing independently *R/t impaired mobility

*Lindane

A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment? *Keratolytic shampoo *Permethrin *Anti-seborrhea shampoo *Lindane

*Normal saline

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal? *Normal saline *Sterile water *Hypertonic solution *Hypotonic solution

Toothbrush *Toothpaste *Emesis basin *Towel Disposable *gloves

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply. *Toothbrush *Toothpaste *Emesis basin *Towel Disposable *gloves *Lip lubricant

*Imbalanced Nutrition: Less than Body Requirements

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis? *Imbalanced Nutrition: Less than Body Requirements *Risk for Infection *Impaired Skin Integrity *Confusion

*She has motivation to participate in self-care.

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? *She has hot water to bathe in. *She has good mobility around her home. *She has motivation to participate in self-care. *She has family and friends who help her with self-care.

*podiatrist.

A client who has been staying at a health care facility for 2 months develops corns on his feet. A corn is a kind of inflammation on the feet. For relief from the corns, the nurse should send this client to a(an): *optometrist. *ophthalmologist. *podiatrist. *dermatologist.

For which of the following clients is foot care likely the highest priority?

A client who is obese and has a diagnosis of type 1 diabetes

*Contact a podiatrist. *Contact health care provider regarding diminished pedal pulses.

A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate? Select all that apply. *Use emery board file to reduce toenail length. *Contact health care provider regarding diminished pedal pulses. *Use orange stick to clean under toenails. Use large clippers to clip toenails. *Contact a podiatrist.

*"Advertised remedies that promise a cure may be a scam."

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response? *"Advertised remedies that promise a cure may be a scam." *"The medication your health care provider prescribed will cure psoriasis." *"This is great news; please let me know how this remedy works for you." *"I know you will feel much better after you have been cured of psoriasis."

*"Since the bed linen is clean, gloves are not necessay unless you are coming into contact with contamined linen."

A licensed practical nurse (LPN) is making an unoccupied bed in preparation for a new admission. What response should the registered nurse (RN) provide to encourage appropriate, effective bedmaking technique and effective use of resources? *"You are demonstrating effective, appropriate bedmaking techinque that also shows an understanding of good use of resources." *"Since your bedmaking technique is appropriate, I'll have you check the new nursing assistants during their orientations." *"Since the bed linen is clean, gloves are not necessay unless you are coming into contact with contamined linen." *"You should spread the sheet out on the entire bed initally to minimize the spread of microorganisms."

*Keep the diaper and buttocks clean and dry and apply zinc oxide.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother? *Leave the baby's buttocks open to air for 2 hours each day. *Apply gentian violet to the buttocks with every diaper change. *Change diaper as soon as it is soiled and apply cornstarch. *Keep the diaper and buttocks clean and dry and apply zinc oxide.

*Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

A nurse assists a client to clean his dentures. Which action should the nurse perform? *Apply force with a 4 × 4 gauze to grasp upper denture plate to remove it. *Pull the bottom denture straight up to remove it from the client's mouth. *Place both dentures in a clean sink to clean them thoroughly. *Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

*Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container.

A nurse is asked to wash the hair of a client who has a spinal cord injury. Which guideline should the nurse follow when performing this procedure? *Use extra padding on the shampoo board before placing it under the client's head. *Only use dry shampoo on a client with a spinal cord injury. *Place a protective pad under the head of the client and divide the hair into four sections to be washed individually. *Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container.

*Provide frequent mouth care. *Arrange for suctioning to remove mucus. *Assist the client to a lateral position.

A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. *Provide frequent mouth care. *Apply mineral oil to the lips. *Arrange for suctioning to remove mucus. *Change the client's position every 2 hours. *Assist the client to a lateral position.

*The client should be placed in a side-lying position to prevent aspiration.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? *The client should be placed in a side-lying position to prevent aspiration. *The client should remain in an upright position to avoid the tongue blocking the airway. *The client should be placed in the lithotomy position. *The client should be placed in a position of comfort.

*clean the dentures over a plastic basin or towel.

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should: *clean the dentures over a plastic basin or towel. *don gloves and free the dentures from the client's mouth. *avoid the use of a toothbrush to clean removable bridges. *store the dentures in an open cup containing only mouthwash.

*"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." *"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." *"Hygiene measures have no affect on skin."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. *"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." *"It is important to include hair care and shampooing along with brushing in your hygiene routine." *"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." *"Bathing regularly and applying lotion and cream as needed are important."

*Attempt to remove the contact lens with a contact lens remover tool.

A nurse is experiencing difficulties when attempting to remove an unconscious client's contact lenses. What would be the most appropriate intervention in this situation? *Gently palpate the client's cornea to dislodge the lens. *Irrigate the client's eye with normal saline. *Attempt to remove the contact lens with a contact lens remover tool. *Do not attempt to remove the contact lens because this will cause damage to the cornea.

*Bathing reduces the possibility of infection.

A nurse is explaining 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 maintains the body temperature. *Bathing prevents skin from peeling. *Bathing reduces the possibility of infection. *Bathing keeps mucous membranes soft and moist.

*Perform hand hygiene.

A nurse is going to bathe a client who is confined to bed. What does the nurse do first? *Close the door or bed curtains. *Perform hand hygiene. *Raise bed to high position. *Lay a towel across the client's chest.

*Do not place soiled dressings or anything with a strong odor in the waste receptacle in the client's room. *In general, keep the room temperature between 20° and 23°C (68° and 74°F). *Avoid carrying out conversations immediately outside the client's room

A nurse is preparing the environment in a hospital room for a newly admitted client. Which actions are recommended? Select all that apply. *Do not store client's personal items in the bedside stand because nurses need to open and close the stand to obtain bath basin, lotion, and other items. *Position client beds at the appropriate height with the wheels unlocked. Follow principles of surgical asepsis at the bedside. *Do not place soiled dressings or anything with a strong odor in the waste receptacle in the client's room. *In general, keep the room temperature between 20° and 23°C (68° and 74°F). *Avoid carrying out conversations immediately outside the client's room

*Check that the bathroom has a nonskid floor.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety? *Check that the bathroom has a nonskid floor. *Check that the grab bars are at shoulder level. *Give the client a damp towel for bathing. *Keep a bottle of bathing oil near the tub.

*White patches may be present that indicate a fungal infection called thrush.

A nurse is providing oral care for a client who has been in a coma for 2 weeks. Which statement should guide the nurse's care plan? *A client who is in a coma has an exaggerated gag reflex that creates a risk for aspiration. *White patches may be present that indicate a fungal infection called thrush. *Oral tissue and structure integrity are not generally affected by a client's cognitive level. *A client who is comatose is at high risk for developing bleeding gums.

*Water should be used to clean an infant's teeth.

A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations? *Toothpaste with fluoride should not be used until children are 16 years of age. * Oral hygiene should begin for children when they are able to hold a toothbrush properly. *Water should be used to clean an infant's teeth. *If a child has braces, mouth rinses should be used instead of a toothbrush to avoid loosening the braces.

*"What are your expectations about bathing at this time?"

A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask? *"Do you want to bathe regularly?" *"What are your expectations about bathing at this time?" * "Are you not able to bathe yourself?" *"What kind of soap do you like to use?"

*Cleanse the perianal area and change the linens with the client in the bed.

A nurse is taking care of an older adult client who was admitted for pneumonia. The client feels very weak and tired but has soiled the linens with urine and feces. What would be the most appropriate action by the nurse? *Cleanse the perianal area and change the linens with the client in the bed. *Have the client go to the bathroom and shower while the linens are changed. *Cover the soiled area and wait until the client has more energy to change the linens. *Don't do anything at this time and wait until the client has rested to change the linens.

*Remove and discard the cap after one use and dry the client's hair with a towel.

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use? *Use the storage warmer to warm cap; do not put the cap in a microwave oven. *Place a towel around the client's shoulders after placing the cap on his or her head. *Leave the cap in place for 5 minutes before beginning to massage the scalp. *Remove and discard the cap after one use and dry the client's hair with a towel.

*Put on gloves before removing soiled linens. *Place a bath blanket over the client. *Help the client turn toward the opposite side of the bed and fan-fold soiled linens as close to the client as possible.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply. *Put on gloves before removing soiled linens. *Place a bath blanket over the client. *Help the client turn toward the opposite side of the bed and fan-fold soiled linens as close to the client as possible. *Grasp the mattress and shift it down to the foot of the bed. *Place soiled linen on the floor. *Secure clean top linens under the head of the mattress.

*using ungloved hands to remove an unconscious client's dentures

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse? *using ungloved hands to remove an unconscious client's dentures *cleaning dentures with tepid water from the sink *encouraging the client to leave the dentures in their mouth overnight *holding dentures over a plastic basin or towel when cleaning them

*"In the absence of fluoridated water supplies, supplementation is often recommended."

A parent reports that their home water is not fluoridated and questions the nurse whether it would be benefitial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate? *"Fluoride supplements are not needed until your child is 13 years of age." *"Using a fluoride-containing toothpaste and mouthwash makes supplementation unnecessary or even dangerous." *"In the absence of fluoridated water supplies, supplementation is often recommended." *"Recommendations about using fluoride supplements have been shown to be outdated."

*Using a tool to remove a contact lens that has adhered to the resident's eye

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? *Shaving the face of a resident who has worn a beard for several years *Using a tool to remove a contact lens that has adhered to the resident's eye *Providing a tub bath to a resident who is unable to mobilize independently *Providing oral care to a client who has cognitive deficits and a decreased level of consciousness

*the importance of completely finishing the prescribed treatment

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits? *the importance of completely finishing the prescribed treatment *the importance of teaching their children adequate personal hygiene habits *the fact that the health problem is self-limiting *the need to destroy all clothing and bedding that the child has used

*alopecia.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: *anxiety. *alopecia. *dandruff. *seborrhea.

Reasons for providing back massage

Acts as a general body conditioner Relieves muscle tension and promotes relaxation Provides opportunity for nurse to observe skin for signs of breakdowns Improves circulation May decrease pain, distress, and anxiety May improve sleep quality

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? Use skin lotion daily and avoid giving bed baths. Provide a tub bath with bath oil every day. Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. Provide a full bed bath with soap and water every day

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

*Assess the client's cultural views regarding hygiene and self-care.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? *Assign a care provider who shares the same culture as the client. *Assess the skin every day using the Braden scale. *Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). *Assess the client's cultural views regarding hygiene and self-care.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. Secretions from skin glands are at their maximum from age 3 on. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. An infant's skin and mucous membranes are protected from infection by a natural immunity.

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? Secretions from skin glands are at their maximum from age 3 on. An infant's skin and mucous membranes are protected from infection by a natural immunity. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness.

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

*Use the toothbrush as planned, despite the client having no teeth.

An older adult client has been admitted to the hospital and the nurse is preparing to provide hygiene to the client. The nurse brings a soft toothbrush and toothpaste to the bedside and the client's daughter begins to laugh, stating, "She doesn't actually have a single tooth left!" What should the nurse do? *Offer the client mouthwash instead of a toothbrush and toothpaste. *Use a 4 × 4 gauze soaked with normal saline to cleanse the client's tongue and gums. *Explain to the client's daughter that her absence of teeth was not documented on admission. *Use the toothbrush as planned, despite the client having no teeth.

*how often the client is bathing.

An older adult client is reporting dry, itching skin. The nurse should assess: *how often the client is bathing. *when the client's last tub bath was. *what linens they are using. *when the severe itching occurs.

*isometric

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? *isotonic *aerobic *isometric *anaerobic

A client is unable to remove their contact lenses after being involved in a motor vehicle crash. What nursing actions can be used to remove the client's soft contact lenses? (Select all that apply.)

Ask the client remove them, if able. Use the pads of the index finger and thumb to gentle pinch and remove the lens. Use a commercially available tool with a small suction cup.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time? Assess both eyes for contact lenses. Ask the unlicensed assistive personnel (UAP) to remove the contact lenses. Contact the client's caregiver and ask if the client wears contacts. Contact the health care provider for a prescription to remove the contact lenses.

Assess both eyes for contact lenses.

perineal and vaginal care

Assess for perineal or vaginal problems and related treatments. Perform a physical assessment of male and female genitalia. Perform perineal care in matter-of-fact and dignified manner according to procedure. Cleanse vaginal area with plain soap and water.

nail and foot care

Assess nails for color and shape, intactness and cleanness, and tenderness. Check for history of nail or foot problems. Soak nails and feet and assist with cleaning and trimming nails (if not contraindicated). Massage the feet to promote relaxation and comfort. Provide diabetic foot care if indicated.

Assess the client's cultural views regarding hygiene and self-care.

A nurse is experiencing difficulties when attempting to remove an unconscious client's contact lenses. What would be the most appropriate intervention in this situation? Irrigate the client's eye with normal saline. Gently palpate the client's cornea to dislodge the lens. Do not attempt to remove the contact lens because this will cause damage to the cornea. Attempt to remove the contact lens with a contact lens remover tool.

Attempt to remove the contact lens with a contact lens remover tool.

Bacteria can flourish in the presence of excessive perspiration. Excessive perspiration will result in potentially offensive odor. Perspiration promotes skin breakdown.

A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply. Bathing can stimulate circulation. Bathing removes organisms from the skin, reducing infection. Bathing decreases comfort because clients are being turned and repositioned. Bathing can improve appearance and self-image. Bathing decreases joint mobility if the client is on bed rest.

Bathing can stimulate circulation. Bathing removes organisms from the skin, reducing infection. Bathing can improve appearance and self-image.

A nurse is explaining 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 reduces the possibility of infection.

hour of sleep care (HS care)

Before the patient goes to bed, offer to toilet them again, wash face and hands, and oral care. This is also a good time for a back massage as patients find it soothing and may help them to fall asleep. Some patients may also find a bath to be soothing and sleep promoting at this time. At this time it is also important to change soiled linens, position the patient comfortably, and ensure the call be is within reach.

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

Breaks in skin integrity and fungal nail infection

The acute care nurse is preparing to bathe a patient and notices that the patient is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which of the following actions by the nurse is most appropriate?

Carefully thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. The gown should be removed without disconnecting the IV equipment or cutting the gown.

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? Select all that apply.

Caries may exist in the teeth, resulting from the failure to remove plaque. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Cheilosis may present as reddened fissures at the angles of the mouth.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety? Check that the grab bars are at shoulder level. Give the client a damp towel for bathing. Keep a bottle of bathing oil near the tub. Check that the bathroom has a non-skid floor.

Check that the bathroom has a non-skid floor.

The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?

Check the nursing care plan for hygiene directives.

care of eyes

Clean from inner to outer canthus with wet, warm cloth, cotton ball, or compress. Use artificial tear solution or normal saline every 4 hours if blink reflex is absent. Care for eyeglasses, contact lens, or artificial eye if indicated.

The nurse manager is preparing to educate newly hired nurses about fingernail hygiene. Which education is appropriate?

Clean under the fingernails when washing hands. No nail treatments can be utilized.

Diabetic foot care

Clean w/ soap and warm water, clean socks everyday, cut toe nails straight across, keep feet dry, no powder or lotion b/t toes , wear shoes , inspect feet daily, no garters

Cleanse the perianal area and change the linens with the client in the bed.

Purpose of Bathing

Cleanses the skin Acts as a skin conditioner Helps to relax a person Promotes circulation Serves as musculoskeletal exercise Stimulates the rate and depth of respirations Promotes comfort through muscle relaxation and skin stimulation Provides person with sensory input Helps improve self-image Strengthens nurse-patient relationship

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An outcome measure was the client will participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?

Client demonstrated bathing independently seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met? Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain. Client is able to wash his upper extremities independently and needs assistance with his lower extremities. Client recognizes the need for self-care and states he is able to perform independently. Bath completed with no distress of discomfort noted.

Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following?

Client will participate in self-care measures by the end of the week.

turgor

Condition of being distended or swollen; normal fullness, elasticity of skin

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention

Contact a podiatrist to care for toenails.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

Contact a podiatrist to care for toenails.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? Use a handheld electric rotary file to reduce length of toenails. Clean under toenails with a wooden orange stick. Clip the toenails with large clippers. Contact a podiatrist to care for toenails.

Contact a podiatrist to care for toenails.

Contact health care provider regarding diminished pedal pulses. Contact a podiatrist.

Corn

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform?

Create a calming environment with little stimuli.

A nurse is asked to wash the hair of a client who has a spinal cord injury. Which guideline should the nurse follow when performing this procedure? Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container. Use extra padding on the shampoo board before placing it under the client's head. Only use dry shampoo on a client with a spinal cord injury. Place a protective pad under the head of the client and divide the hair into four sections to be washed individually.

Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across

A nurse has finished providing morning care for the client. Which safety measures should the nurse employ prior to leaving the client's room? Select all that apply. A- Remove excess sheets from the room. B- Leave the client lying flat. C- Ensure the bed is locked. D- Place the bed in the lowest position. E- Place all four side rails up. F- Place the call light near the client within reach. G- Test the functioning of the bed and bed controls.

D G F C NO to A,B, and E

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia

The nurse is planning hygiene care for a client with self care bathing deficit related to weakness. Which nursing intervention is appropriate?

Encourage the client to wash own face and hands.

he nurse is planning hygiene care for a client with self-care bathing deficit related to weakness. Which nursing intervention is appropriate?

Encourage the client to wash own face and hands.

Afternoon care, PM care

Ensure that the patient is comfortable after lunch and offer assistance with toileting, handwashing, and oral care. Straighten the bed or help someone to reposition for comfort.

Excessive perspiration will result in potentially offensive odor. Bacteria can flourish in the presence of excessive perspiration. Perspiration promotes skin breakdown.

The nurse is caring for an older adult client who has refused a bath for several days and has now developed a rash on the buttocks. What is the priority nursing intervention?

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention? Encourage client to help with self-hygiene as able. Offer a choice of types of soap and shampoo. Schedule bath in the morning or evening according to client's preferred bathing time. Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

A nurse is making an occupied bed. What is a recommended guideline for this procedure?

Fan-fold soiled linens as close to the client as possible.

A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure?

Fan-fold soiled linens as close to the client as possible.

A nurse is making an unoccupied bed for a hospitalized client. Which actions are appropriate steps for the nurse to perform? Select all that apply.

First, adjust the bed to the high position and lower the side rails. Fold reusable linens on the bed in fourths and hang them over a clean chair. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. Tuck the bottom sheets securely under the head of the mattress to form a corner, according to agency policy.

Flossing removes plaque and food debris from the surfaces of teeth that a manual or electric toothbrush may miss. The choice of unwaxed or waxed floss is personal. Waxed floss is thicker and more difficult to insert between teeth; unwaxed floss frays more quickly. The nurse should not share his or her own personal experiences, but rather, educate the patient on the need to use flossing in addition to brushing to maintain good oral hygiene.

Foot care is an essential part of routine hygiene. What is an important nursing consideration when planning foot care for clients with diabetes?

Foot care should not include soaking the feet.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation?

Gently slide the hard lens over the cornea and remove it with gloved fingers.

A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis Other definitions: Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition."

Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.

Guidlines for assession skin

Head-to-toe good source of light preferable light check for bilateral symmetry report and record findings allow data obtained to direct skin assessment identify variables known to causes skin problems

Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visiting the dentist every six months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damage the hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansing the skin regularly using lotions and creams while ensuring good cleansing of the axilla and application of deodorant and antiperspirants; and cleaning the perineal areas. Hygiene also promotes a sense of well-being and positive self-image.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which methods for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps

How often the client brushes and flosses the teeth

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps?

How often the client brushes and flosses the teeth

Which nursing actions are recommended guidelines when performing oral care?

Ideally, brush teeth immediately after eating or drinking. If desired, use an automatic toothbrush to remove debris and plaque from teeth. If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

*When inserting an endotracheal tube

In which situation would it be appropriate to shave the beard of an unconscious client without his permission? *To facilitate skin care *When inserting an endotracheal tube *To facilitate use of a nebulizer *When the beard becomes tangled

Independent showering

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings? Partial care Independent showering The client should not be bathed Complete bed bath

Independent showering

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?

Inform the UAP that she should be wearing gloves.

A nurse assists a client to clean his dentures. Which action should the nurse perform?

Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

What are recommendations that should be given to clients with poor circulation in order to prevent problems with their feet? Select all that apply.

Inspect feet daily. Avoid crossing your feet. A person with poor circulation should never use sharp instruments to cut nails as they can cause damage to the foot itself. Furthermore, they should always wear shoes to protect their feet. Soaking the feet causes them to dry out and can cause cracking.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.)

Keep extra batteries on hand.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point? Use cosmetics and emollients to cover the condition. Keep hair off the face and wash hair daily. Wash your face less frequently to avoid removing beneficial oils. Gently squeeze the infected areas to release the infection.

Keep hair off the face and wash hair daily.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother

Keep the diaper and buttocks clean and dry and apply zinc oxide.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother? Apply gentian violet to the buttocks with every diaper change. Change diaper as soon as it is soiled and apply cornstarch. Leave the baby's buttocks open to air for 2 hours each day. Keep the diaper and buttocks clean and dry and apply zinc oxide.

Keep the diaper and buttocks clean and dry and apply zinc oxide.

When caring for a client with dentures, what should the nurse teach the client?

Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients items. Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide? Squeeze the lesion to release pus. This chronic skin disorder is noninfectious. Nits may be present on hairs under the axillae. Launder personal bath items in hot water and bleach.

Launder personal bath items in hot water and bleach.

patient outcome achievement

Level of patient participation in hygiene program Elimination of, reduction in, or compensation for factors interfering with independent execution of hygiene measures Changes related to specific skin problems and independent patient management of prescribed treatment program

A school nurse is conducting a teaching session for the parents of elementary school students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

A school nurse is conducting a teaching session for the parents of elementary students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

At risk for skin alteration

Lifestyle factors Changes in health state Illness Diagnostic measures Therapeutic measures

A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment?

Lindane

Assessment of the Oral Cavity

Lips Buccal mucosa Color and surface of gums Teeth Tongue Hard and soft palates Oropharynx

administering oral hygiene

Moistening the mouth Cleaning the mouth Caring for dentures Toothbrushing and flossing Using mouthwashes

A 45-year-old woman has multiple sclerosis. She is able to perform most functions of self-care but recently she has been having problems with balance, which has made it hard to get dressed. Which factor is affecting this client's ability to perform self-care?

Neuromuscular

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the client's lenses after removal?

Normal saline

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal? Sterile water Hypertonic solution Hypotonic solution Normal saline

Normal saline

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that he is wearing contact lenses. What is the priority action by the nurse? Irrigate the eyes with 0.9% normal saline to aid in removal of the contact lenses. Notify the emergency department health care provider that the client is wearing contact lenses. Remove the contact lenses and place in a storage case marked L and R. Ask the client to remove the contact lens from the unaffected eye and place in a storage case marked L or R.

Notify the emergency department health care provider that the client is wearing contact lenses.

physical assessment of oral cavity

Observe for oral problems. Dental caries Periodontal disease Other oral problems Identify actual or potential oral problems that nurses can treat. Identify appropriate nursing measures. Carry out the plan of care.

As needed care PRN care

Offer individual hygiene measures as needed. Change clothing and bed linens of diaphoretic patients. Provide oral care every 2 hours if indicated.

A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of which of the following?

Pediculosis

A nurse is going to bathe a client who is confined to bed. After reviewing the client's record, what does the nurse do next?

Perform hand hygiene

A nurse is going to bathe a client who is confined to bed. What does the nurse do first?

Perform hand hygiene

A nurse has finished providing morning care for the client. Which safety measures should the nurse employ prior to leaving the client's room?

Place the bed in the lowest position. Test the functioning of the bed and bed controls. Place the call light near the client within reach. Ensure the bed is locked.

Providing a bed bath

Provide articles for bathing on overbed table or bedside stand. Provide privacy for patient. Remove top linens and replace with bath blanket. Place cosmetics in convenient place. Assist patients who cannot bathe themselves completely.

A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client?

Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position.

A nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.

The nurse has been providing care to a client throughout the day. What interventions would the nurse perform to maintain hygienic practices with the client? Select all that apply.

Provide the client with washcloths, one with soap and another without soap, after each toileting. Obtain chlorhexidine disposable washcloths to use for cleansing after bowel movements. Provide a back rub for 4 to 6 minutes after the client's bath. Place an emesis basin on the bedside table to assist the client with brushing and flossing of teeth.

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? Providing multiple stimuli to make the client tired Giving the client something to drink Providing a back rub before bed Engaging in a therapeutic conversation

Providing a back rub before bed

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

Providing a backrub before bed A backrub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?

Pull down on the lower lid and exert slight pressure below the lid.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task? Pull the inner canthus toward the bridge of the nose and lift under the glass. Apply pressure over the eye with your index finger and thumb under the eye. Pull up the upper lid and place your index finger under the glass edge. Pull down on the lower lid and exert slight pressure below the lid.

Pull down on the lower lid and exert slight pressure below the lid.

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokes.

A nurse is shaving a male client's face. Which should the nurse do? Shave against the direction of hair growth, using short strokes. Pull the skin taut and shave in the direction of hair growth using short strokes. Pull the skin taut and use short, upward strokes. Let the skin hang loose and shave in long, downward strokes.

Pull the skin taut and shave in the direction of hair growth using short strokes.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? R/t the inability to recognize the need to urinate or defecate R/t right-sided weakness R/t the inability to perform bathing independently R/t impaired mobility

R/t right-sided weakness Self-care deficit: Bathing is related to lack of motor skills, coordination, mental status, and endurance when performing bathing activities. Right-sided weakness is an appropriate statement about why this problem exists. A person's inability to perform bathing independently is more of a sign or symptom in the "as evidenced by (AEB)" statement of a nursing diagnosis. Related to impaired mobility is a nursing diagnosis and cannot be used as a "related/to" statement.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? Place a protective pad under the client's head and shoulders. Place a drain container underneath the drain of the shampoo board. Raise the bed to elbow height. Close curtains around the bed and close the door to the room, if possible.

Raise the bed to elbow height.

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use?

Remove and discard the cap after one use and dry the client's hair with a towel.

Which nursing action is appropriate when providing foot care for a client

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms

Which nursing action is appropriate when providing foot care for a client? Cut off any corns or calluses. Soak the feet in a solution of mild soap and tepid water. For diabetic clients, trim the nails with nail clippers. Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

She has motivation to participate in self-care.

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? She has good mobility around her home. She has hot water to bathe in. She has motivation to participate in self-care. She has family and friends who help her with self-care.

She has motivation to participate in self-care.

A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals

She has motivation to participate in self-care. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her

She has motivation to participate in self-care. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

What type of bath is preferred to decrease the inflammation after rectal surgery?

Sitz bath A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.

excoriation

Skin sore or abrasion produced by scratching or scraping

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? Keep dentures near you in the bed for easy access. Store dentures in cold water when not in use. Remove dentures whenever possible to rest the gums. Wrap dentures in a napkin when not using them.

Store dentures in cold water when not in use.

A nurse is educating a client on how to care for her dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

A nurse is educating a client on how to care for their dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures?

Store the client's dentures in water when the client is not wearing them.

A nurse is explaining the use and handling of dentures to an older adult client. What measures should the nurse mention to the client? Keep the dentures wrapped in tissue. Clean the dentures in hot water. Store the dentures in water in a covered cup. Clean the dentures with a tissue

Store the dentures in water in a covered cup.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in cool environment.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Clean the hearing aid with a bleach. Do not change batteries by yourself. Store the hearing aid in cool environment. Use sandpaper to clean off hardened cerumen residue.

Store the hearing aid in cool environment.

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client?

Suction toothbrush

*"To preserve the client's functional ability to grasp and pick up objects."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? *"To preserve the client's functional ability to grasp and pick up objects." *"To prevent foot drop." *"To avoid contractures." *"To prevent the legs from rotating outward."

Ensuring Bedside Safety

The bed is in its lowest position. The bed position is safe for the patient. The bed controls are functioning (bed is electrically safe). Call light is functioning and always within reach Side rails are raised if indicated. The wheels or casters are locked.

The nurse is caring for a client who voices concerns about the development of her 8-month-old daughter. Which finding would be a source of concern?

The child is unable to hold a spoon to attempt self-feeding.

The nurse is assisting a 56-year-old female who has undergone a mastectomy with her morning care. Which action by the client requires further teaching by the nurse?

The client applies deodorant.

The nurse is assisting a 56-year-old female, who has undergone a mastectomy, with her morning care. Which action by the client requires further teaching by the nurse?

The client applies deodorant.

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?

The client is at risk for caries due to eroding tooth enamel.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? The client should be allowed to complete as much of the bath as he can. The nurse should bathe the man herself, as he has dementia. The nurse should have a male nurse bathe the client. The nurse should call a family member and have him or her bathe the man.

The client should be allowed to complete as much of the bath as he can.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? The client should be placed in a position of comfort. The client should be placed in a side-lying position to prevent aspiration. The client should remain in an upright position to avoid the tongue blocking the airway. The client should be placed in the lithotomy position.

The client should be placed in a side-lying position to prevent aspiration.

The client should use an electric razor.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? The client prefers shaving gel over shaving cream. The client should use an electric razor. The client would like the spouse to assist with shaving. The client likes to shave while in the shower.

The client should use an electric razor.

*"It is important to keep the room at a comfortable temperature for the client." *"Always ask the client if anything is needed before you leave the room." *"When I place soiled items in the client's trash, I will remove the bag from the room when I leave."

The health care environment can be very stressful for a client. During an orientation session of nursing students, the nursing instructor teaches students how to minimize a stressful environment. Which statement from the students indicates the teaching was effective? Select all that apply. *"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." *"We should discuss the client's condition outside of the room in order not to violate HIPAA." *"It is important to keep the room at a comfortable temperature for the client." *"Always ask the client if anything is needed before you leave the room." *"Spray the room daily with Lysol to reduce the spread of germs and maintain a sterile smell to assure the client it's clean."

*The client applies deodorant.

The nurse is assisting a 56-year-old female who has undergone a mastectomy with her morning care. Which action by the client requires further teaching by the nurse? *The client applies deodorant. *The client provides care independently. *The clients applies cosmetics after her bath. *The client uses a bag bath.

*26-year-old who is suicidal and requests to shave *30-year-old with inflammation of facial skin *68-year-old taking anticoagulants for deep venous thrombosis *45-year-old with liver disease and impaired clotting

The nurse is assisting with morning care for a group of clients. For which clients is a safety razor contraindicated? Select all that apply. *68-year-old taking anticoagulants for deep venous thrombosis *45-year-old with liver disease and impaired clotting *45-year-old with pneumonia who prefers to shave twice daily *26-year-old who is suicidal and requests to shave *30-year-old with inflammation of facial skin

*Use small amounts of water and an oral suction device.

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care? *Use small amounts of water and an oral suction device. *Place the client in high Fowler's position. * Place the client in the supine position with head lowered. *Put the client in the prone position.

*Launder personal bath items in hot water and bleach.

The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide? *Squeeze the lesion to release pus. *Launder personal bath items in hot water and bleach. *This chronic skin disorder is noninfectious. *Nits may be present on hairs under the axillae.

*underneath the breasts and in between skinfolds

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? *underneath the breasts and in between skinfolds *underneath the fingernails and toenails * the inner and outer canthus of each eye *the antecubital fossa and popliteal space

*Pull down on the lower lid and exert slight pressure below the lid.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task? *Apply pressure over the eye with your index finger and thumb under the eye. *Pull up the upper lid and place your index finger under the glass edge. *Pull the inner canthus toward the bridge of the nose and lift under the glass. *Pull down on the lower lid and exert slight pressure below the lid.

*51-year old with hemorrhoids

The nurse is caring for four clients. For which client is a sitz bath most appropriate? *42-year old recovering from a C-section delivery *51-year old with hemorrhoids *60-year old who is 1-day postop from a knee replacement *73-year old with pneumonia who can get up to bedside commode

*placing the client in good alignment with joints slightly flexed

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? *helping the client change positions every 4 hours *placing the client in good alignment with joints slightly flexed *providing skin care before repositioning *using a sheet to drag and lift the client

*Excessive perspiration will result in potentially offensive odor. *Bacteria can flourish in the presence of excessive perspiration. *Perspiration promotes skin breakdown.

The nurse is discussing hygiene with a client. The client states that not understanding the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply. *Perspiration may result in viral growth if not managed frequently. *Excessive perspiration will result in potentially offensive odor. *Bacteria can flourish in the presence of excessive perspiration. *There is no medical rationale to avoid excessive perspiration. *Perspiration promotes skin breakdown.

*Inspect feet daily. *Avoid crossing your leg and feet.

The nurse is educating a client with poor peripheral circulation about the importance of caring for their feet. What should the nurse provide regarding foot care in order to prevent complications? Select all that apply. *Inspect feet daily. *Avoid crossing your leg and feet. *Cut thick toenails with a sharp razor or knife. *Walk barefoot whenever possible to air feet out. *Soak feet in hot water once a day.

*pulling the razor against the direction of hair growth

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? *washing the skin with soap and water prior to shaving *pulling the razor against the direction of hair growth *rinsing the razor after each stroke of the razor *applying direct pressure to an area that is bleeding

*shortness of breath after walking up five stairs

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? *a change in pulse from 80 to 84 after walking up 20 stairs *shortness of breath after walking up five stairs *joint stiffness after sitting for an hour *walking with a slow and uncoordinated movement

*Heat the entire package in the microwave, following the manufacturer's recommendation.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct? *Heat the entire package in the microwave, following the manufacturer's recommendation. *Place the washcloths in warm water, one at a time, in the order that they will be used. *Twenty minutes before beginning the bath, place the unopened package underneath the small of the client's back. *Fill the sink with hot water, place the unopened package in the water, and let it soak for at least 10 minutes.

*traditional bed bath with linen change

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? *traditional bed bath with linen change *shower with assist *bag bath *tub bath

*Check the order within the plan of care for hygiene.

The nurse is preparing to provide hygiene for a client with obesity who has bed rest ordered for 3 days. What is the priority nursing intervention that will be performed to deliver hygiene care? *Assess the client's level of consciousness. *Check the order within the plan of care for hygiene. *Gather linens, soap, and shampoo. *Plan for ways to move the client with assistance of another nurse.

*"Picture yourself with good posture standing; that is how good lying posture works."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? *"Picture yourself with good posture standing; that is how good lying posture works." *"Keep knees and legs very straight." *"Your feet should be at 45-degree angles from the legs." *"Sleep with your head tilted to one side to take pressure off your neck."

*"I will rinse with water when I cannot brush." *"I will increase my intake of calcium." *"I will not chew ice cubes or crushed ice."

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? Select all that apply. *"I will brush once a day." *"I will rinse with water when I cannot brush." * "I will drink clear soda instead of brown soda." *"I will increase my intake of calcium." *"I will not chew ice cubes or crushed ice."

*"Hold dentures over a plastic basin or towel when cleaning them."

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? *"Use your ungloved hands to remove an unconscious client's dentures." *"Clean dentures with hot water to eliminate bacteria." *"After brushing dentures, leave them out of the client's mouth overnight." *"Hold dentures over a plastic basin or towel when cleaning them."

*No nail treatments can be utilized. *Clean under the fingernails when washing hands.

The nurse manager is preparing to educate newly hired nurses about fingernail hygiene. Which education is appropriate? Select all that apply. *Use fingernail polish instead of artificial nails. *Gel polish is an acceptable method of polishing nails. *No nail treatments can be utilized. *Clean under the fingernails when washing hands. *Acrylic nail treatments help strengthen nails since nurses wash hands often.

*Remind the nurse that artificial fingernails can spread fungal infections. *Refer the nurse to the agency policy on artificial fingernails. *Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene.

The nurse manager notices that a nurse is wearing artificial fingernails. What is the appropriate nurse manager action? Select all that apply. *Remind the nurse that artificial fingernails can spread fungal infections. *Refer the nurse to the agency policy on artificial fingernails. *Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene. *Demand that the nurse remove the artificial fingernails immediately. *Ask the nurse to use only fingernail polish instead of artificial fingernails.

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

The nurse must value and support the client becoming independent in care.

*Use soap daily when bathing to remove debris and keep skin moist.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? *Obtain a tub or shower seat if the client has mobility issues. *Check bath water temperature before allowing the client to bathe. *Grab bars should be placed in the shower or tub at arm level. *Use soap daily when bathing to remove debris and keep skin moist.

*Use bath oil in the tub to decrease dry skin.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? *Obtain a tub or shower seat if the client has mobility issues. *Use bath oil in the tub to decrease dry skin. *Grab bars should be placed in the shower or tub at arm level. *Soap should be used sparingly so the client's skin does not become overly dry.

*"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction? *"Brushing is important to remove bacteria from the mouth and teeth." *"Tartar cannot be brushed or flossed way." *"Flouride treatments are needed until my children reach the age of 14." *"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

Positioning the client's bed for safety is an important nursing measure. What must the nurse assure before leaving the client's room?

The wheels or casters are locked.

corn

A client reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which of the following? Select all that apply. Heredity Thermal extremes Adverse reaction to medications Poor oral hygiene Bacteria

Thermal extremes Poor oral hygiene Adverse reaction to medications Bacteria

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate?

Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath.

Traditional bed bath with linen change

The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning? Use a special cleaning solution for eye glass lenses Use hot water when cleaning the plastic frames to remove debris Use a silicone tissues to clean plastic lenses Dry the lenses very carefully with a paper towel

Use a special cleaning solution for eye glass lenses

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching.

When bathing a patient, the nurse notices that the patient has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching.

Use bath oil in the tub to decrease dry skin.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Use electric razor for shaving purposes.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? Buy hard-bristle toothbrush to ensure proper oral hygiene. Take aspirin for headaches that develop. Use electric razor for shaving purposes. Reassure client that prolonged bleeding of wounds and gums is normal.

Use electric razor for shaving purposes.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply. Use vigorous rubbing motions when drying the skin to increase circulation. Use a long-handled shower brush or attachment to help with limited mobility. Use of a tub/shower seat may be necessary if balance problems are present. Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently. Water temperature should be monitored carefully due to decreased temperature sensation.

Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

Which modification to bathing should be implemented for a client who is incontinent? Perform a full bed bath each time the client has an episode of incontinence. Use special perineal skin cleaners and moisture barriers. Decrease the frequency of bathing to preserve skin integrity. Use a topical antiseptic, such as povidone-iodine, in the perineal area.

Use special perineal skin cleaners and moisture barriers.

Which of the following modifications to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers. Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation.

Use the toothbrush as planned, despite the client having no teeth.

The client questions the nurse about the best manner to clean the ears. What should be included in the information provided to the client?

Use the twisted end of a clean washcloth and pull auricle down

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)?

Using a tool to remove a contact lens that has adhered to the resident's eye

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? Providing a tub bath to a resident who is unable to mobilize independently Providing oral care to a client who has cognitive deficits and a decreased level of consciousness Shaving the face of a resident who has worn a beard for several years Using a tool to remove a contact lens that has adhered to the resident's eye

Using a tool to remove a contact lens that has adhered to the resident's eye

ear and nose care

Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs. Perform hearing aid teaching and care if indicated. Clean nose by having patient blow it if both nares are patent. Remove crusted secretions around nose by applying warm, moist compress.

A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations?

Water should be used to clean an infant's teeth.

*hair should be washed as often as necessary.

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: *braids should be undone every day. *combs should be washed as often as necessary. *hair should be washed as often as necessary. *lubricants or oils should not be used on the braids.

*Use a tepid bath to relieve inflammation and itching.

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? *Avoid washing the area because cleansing agents will only make the rash worse. *Use a tepid bath to relieve inflammation and itching. *Do not use over-the-counter products on unknown rashes. *Use a moisturizing lotion on a wet rash to prevent itching.

*Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit.

When caring for a client with dentures, what should the nurse teach the client? *Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit. *Dentures should be wrapped in tissue or a disposable wipe when out of the mouth and stored in a disposable cup. *Dentures should never be stored in water because the plastic material may warp. *A brush and nonabrasive powder should be used to clean the dentures, and hot water should be used to rinse them.

In which situation would it be appropriate to shave the beard of an unconscious client without his permission?

When inserting an endotracheal tube

The nurse is changing the linens of a client's bed. The client is still occupying the bed. What is the nurse's most appropriate action?

When making an occupied bed, the nurse should ensure that the siderails are up to protect the client from falls. As well, gloves should be worn for infection control.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

*The client is at risk for caries due to eroding tooth enamel.

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate? *The client is at risk for caries due to eroding tooth enamel. *The client is at risk for tartar due to eroding tooth enamel. *The client is at risk for gingivitis due to eroding tooth enamel. *The client is at risk for periodontal disease due to eroding tooth enamel.

*Before removing hard lenses, use gentle pressure to center the lens on the cornea.

Which guideline should the nurse follow when removing contact lenses from a client's eyes? *Before removing hard lenses, use gentle pressure to center the lens on the cornea. *Once removed, place both lenses in a cup and label the cup with the name of the client. *If an eye injury is present, remove lenses immediately to avoid causing additional injury. *If the contact lenses cannot be easily removed, they will have to be removed by the health care provider under sterile conditions.

*Ask the client to remove them, if able. *Use the pads of the index finger and thumb to gently pinch and remove the lens.

Which methods can be used to remove a client's soft contact lenses? Select all that apply. *Ask the client to remove them, if able. *Use the pads of the index finger and thumb to gently pinch and remove the lens. *Use a commercially available tool with a small suction cup. *Apply gentle pressure to the lower eyelid until the lens pops out. *Use two cotton-tipped applicators to gently grasp the lens.

*Ideally, brush teeth immediately after eating or drinking. *If desired, use an automatic toothbrush to remove debris and plaque from teeth. *If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

Which nursing actions are recommended guidelines when performing oral care? Select all that apply. *Use a hard toothbrush to remove plaque from the teeth. *Ideally, brush teeth immediately after eating or drinking. *Never clean the tongue with a toothbrush. *If desired, use an automatic toothbrush to remove debris and plaque from teeth. *Never use water-spray units to assist with oral hygiene. *If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

*Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side.

Which statement accurately describes a recommended step when making an unoccupied bed? *Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side. *Fold reusable linens (such as sheets, blankets, or spread) in half and hang them over a clean chair. *Snugly roll all the soiled linen inside the top sheet and place directly into the laundry hamper. *Place the top sheet on the bed with its centerfold at the head of the bed and with the hem even with the bottom of the mattress.

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client?

Yes, these can obstruct lower extremity circulation.

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

a thorough, mechanical cleaning

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: dandruff. seborrhea. alopecia. anxiety.

alopecia

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:

alopecia -alopecia is hairloss

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:

assess the client's safety.

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:

assessment of tissues.

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP) Assessments and wound care must be done by the RN.

back massage

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?

back massage

A nurse is selecting a product to provide a complete bed bath to a client who is on bed rest. Which product would be best to use in this manner?

body foam

furuncle

boil; suppurative inflammatory skin lesion due to infected hair follicle

Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition

caries

Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition?

caries -The combination of sugar, plaque, and bacteria may eventually erode the tooth enamel, causing caries (cavities).

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should:

clean the dentures over a plastic basin or towel.

factors to consider when examining skin

cleanliness, color, temperature, turgor, moister, sensation, vascularity, evidence of lesions

Purpose of bathing

cleanse the skin can relax patient promotes circulation improved self image stimulates rate/depth of respirations

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be: client will consent to no hygiene measures. client will verbalize the need to use to use the bedpan by the end of shift. client will recognize the need for self-care. client will participate in self-care measures by the end of the week.

client will participate in self-care measures by the end of the week.

Factors affecting Personal Hygeine

culture, socioeconomic, spiritual practices, developmental level, health state, personal preferences

UAP's can not provide foot care to a patient with

diabetes or cut their toenails

Self-Care Deficit Diagnosis

feeding bathing and hygiene dressing and grooming toileting

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: lubricants or oils should not be used on the braids. combs should be washed as often as necessary. hair should be washed as often as necessary. braids should be undone every day.

hair should be washed as often as necessary

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:

hair should be washed as often as necessary.

An older adult client is reporting dry, itching skin. The nurse should assess:

how often the client is bathing.

When the nurse cleanses the client's leg during a bed bath, it will allow for: increased circulation. promotion of social interaction. decreased restless leg syndrome. assessment of pain.

increased circulation.

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation. Bathing increases circulation and helps maintain muscle tone and joint mobility.

stomatitis

inflammation of the oral mucosa

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client to avoid that is on the dietary tray?

jelly to go on the toast

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client's to avoid that is on the dietary tray?

jelly to go on the toast

Hearing aid care

keep the hearing aid dry clean the ear mold with mild soap and water while avoiding excessive wetting use a tooth pick to clean out debrie in the midde part that goes into ear turn off when not in use check and replace battery frequently keep hearing aid in safe place do not drop it or expose to extreme temps have at lowest setting that allows you to hear to prevent feedback squeaking avoid using hairspray, cosmetics, oils, or other hair and face products if hearing aid doesnt work-check the battery, the connection between the ear and the receiver, on/off switch, clean sound hole, adjust volume, taking hearing aid to service

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? client's allergies to soap since shaving cream is contraindicated in the hospital medications listed on the client's medication administration record (MAR) cultural views and attitudes toward facial hair and grooming the last time shaving was performed because clients can only shave twice weekly in the hospital

medications listed on the client's medication administration record (MAR)

medications listed on the client's medication administration record (MAR) Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety.

The nurse notices multiple caries upon inspecting a client's mouth. When asked if the client has dental pain, the client responds, "No, my teeth and gums never hurt." Which structural damage does the nurse anticipate? root nerve enamel gingiva

nerve

nerve Nerve damage has occurred if the client does not feel sensation or pain. Enamel, root, and gingiva damage do not cause decreased sensation or pain.

During morning care, the nurse notices a glasslike appearance to the client's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretions related to illness? boric acid solution hydrogen peroxide solution normal saline solution soap and water

normal saline solution

A kindergarten student is sent to the school nurse because they have been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:

pediculosis.

Which health problem is most clearly suggestive of a history of inadequate dental care?

periodontitis

The nurse has delegated oral care for an unconscious client to an unlicensed assistive personnel (UAP). Which UAP action requires immediate nursing intervention?

placing the client supine to perform mouth care -The unconscious client is at risk for aspiration; the nurse must intervene to correct the UAP's positioning of the client.

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

pulling the razor against the direction of hair growth

R/T

related to

common in older adults.

senile lentigines (brown, flat patches on the face, hands, and forearms)

Early Morning Care

shortly after the patient wakes up, assisting them with toileting and then providing comfort measures to refresh the patient and prepare them for breakfast, including washing the face and hands and providing mouth care.

A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?

sit-down shower with shower chair

A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?

sitz bath

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?

the importance of completely finishing the prescribed treatment

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits? the importance of completely finishing the prescribed treatment the need to destroy all clothing and bedding that the child has used the fact that the health problem is self-limiting the importance of teaching their children adequate personal hygiene habits

the importance of completely finishing the prescribed treatment

there is a need to determine if the bottled water has fluoride.

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: the preschool child should not drink bottled water. there is a need to determine if the bottled water has fluoride. the parent should alternate bottle and tap water. the preschool child should only drink milk.

there is a need to determine if the bottled water has fluoride.

morning care, am care

toileting, oral care, bathing, back massage, special skin measures, hair care, cosmetics, dressing, positioning for comfort, refresh or change bed linens, tidy up bedside

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? tub bath shower with assist bag bath traditional bed bath with linen change

traditional bed bath with linen change

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?

underneath the breasts and in between skin folds

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? underneath the breasts and in between skin folds the inner and outer canthus of each eye underneath the fingernails and toenails the antecubital fossa and popliteal space

underneath the breasts and in between skin folds

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:

understand that his culture may influence his hygiene and ask him his preference.

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: give the client a bath pan and tell him she will return when he has finished. understand that his culture may influence his hygiene and ask him his preference. ask another nurse to assist in giving the client a complete bath every other day. Encourage the client to bathe daily as part of protection from infection.

understand that his culture may influence his hygiene and ask him his preference.

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse?

using ungloved hands to remove an unconscious client's dentures

The nurse is changing a client's bedding. When removing the soiled sheets, what is the nurse's best action?

wrapped inside itself help away from the body - It is important to avoid any unnecessary contact with a client's soiled bedding to maintain the principles of infection control. The nurse must hold the bedding away from the front of his or her torso. Gloves must be worn during this task.

• Bathing can improve appearance and self-image. • Bathing can stimulate circulation. • Bathing removes organisms from the skin, reducing infection.

Which nursing actions are recommended guidelines when performing oral care? Select all that apply.

• Ideally, brush teeth immediately after eating or drinking. • If desired, use an automatic toothbrush to remove debris and plaque from teeth. • If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

ch. 31 hand hygiene questions

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