Chapter 24. Hygiene

27. Which is a benefit of bathing? Select all that apply. 1) Constricts blood vessels 2) Increases depth of respirations 3) Gives opportunity for assessments 4) Reduces sensory input 5) Increases cardiac output

ANS: 2,3

14. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath

ANS: 3

2. The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient. 2) Use cool water for bathing. 3) Provide care in small intervals. 4) Rub briskly when towel drying

ANS: 3

6. A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1) Risk for Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity

ANS: 2

9. A patient with diarrhea is incontinent of liquid stool. The nurse documents that the patient has excoriated skin on the buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) The epidermal layer of skin was rubbed away. 4) A lesion caused by tissue compression was present.

ANS: 2

1. The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? 1) Use an electric razor for shaving. 2) Apply skin moisturizer. 3) Use less soap when bathing. 4) Floss teeth daily.

ANS: 1

10. For which patient problem is it most important to provide frequent perineal care? 1) Active lower gastrointestinal bleeding 2) Recovering from diabetic ketoacidosis 3) Has a circumcised penis 4) History of acute asthma

ANS: 1

13. Which action should the nurse take when preparing a patient for a bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from the bed. 3) Have the patient completely bathe himself to promote independence. 4) Wash the patient's body without assistance from the patient.

ANS: 1

16. The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1) "I can contract the infection by walking barefoot in the gymnasium's showers." 2) "The best way to avoid contracting the infection is to use good hand washing." 3) "Wearing unventilated shoes prevents the fungus from gaining contact with my feet." 4) "There is really no way to prevent its spread; it's highly contagious."

ANS: 1

18. While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest? 1) Inadequate dietary intake 2) Normal aging process 3) Fungal infection 4) Excessive use of silver salts

ANS: 1

21. Which item is best for providing mouth care for an unconscious patient? 1) Foam swabs 2) Lemon-glycerin swabs 3) Hydrogen peroxide 4) Cotton-tipped applicator soaked in mouthwash

ANS: 1

25. The nurse reviews contact lens care with a client. Which statement indicates that teaching has been effective? 1) "I will use saline to clean my lenses." 2) "I will place my lenses on the counter." 3) "I will keep my lenses in when using eye drops." 4) "I will wash my hands after removing my lenses."

ANS: 1

7. What is the body's first line of defense against bacteria? 1) Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response

ANS: 1

28. For which patient should the nurse avoid using back massage? Select all that apply. 1) Underwent heart surgery 3 days ago 2) Sustained rib fractures from a fall 3) Recovering from a lumbar laminectomy 4) Sustained a leg fracture in a sledding accident 5) Receiving treatment for full-thickness burns

ANS: 1, 2, 5

26. Which area should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. 1) Buccal mucosa 2) Around the lips 3) Palms 4) Tongue 5) Nailbeds

ANS: 1, 3, 4

30. The nurse prepares to change a client's bed. Which actions will the nurse take to minimize the effects of the environment during this task? Select all that apply. 1) Avoid shaking the linen 2) Place pillows on the sink 3) Place used linen on the floor 4) Hold contaminated linen away from the body 5) Fold and place bedspread on the roommate's chair

ANS: 1, 4

11. A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into the bathtub. 2) Wait for the patient to calm down, and then give him a towel bath. 3) Allow the patient to go without bathing for a day or two. 4) Ask another staff member to attempt the tub bath.

ANS: 2

22. After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1) pediculosis. 2) alopecia. 3) dandruff. 4) hirsutism.

ANS: 2

23. Which statement describes a correct step in removing and cleaning a hearing aid? 1) Clean only the external surfaces, not the canal portion. 2) Clean the top part of the canal portion of the device. 3) Insert a wax loop or toothpick into the hearing aid. 4) Remove the battery before taking the hearing aid from the ear.

ANS: 2

3. A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Feeding Self-care Deficit 2) Bathing Self-care Deficit 3) Dressing Self-care deficit 4) Activity Intolerance

ANS: 2

24. The nurse prepares to remove the artificial eye of a patient sitting at the bedside. In which position should the patient be placed to facilitate the removal of this device? Ask the patient to: 1) Lean forward and rest the arms on the overbed table. 2) Sit back in the chair and tilt the head back. 3) Move to the bed and lie down. 4) Stand up and lean over the bed.

ANS: 3

5. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

ANS: 3

8. While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Pallor. 2) Erythema. 3) Jaundice. 4) Cyanosis.

ANS: 3

29. The nurse notes that a community member is unkempt and has body odor. What should the nurse consider as impacting this client's hygienic practices? Select all that apply. 1) Illness 2) Lack of desire 3) Water in the home 4) Money to buy hygiene supplies 5) Lack of knowledge about bathing

ANS: 3, 4

12. The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? 1) "Cleanse only those areas likely to cause odor." 2) "Provide the patient with warm water for washing his perineum." 3) "Wash the patient's back, buttocks, and perineum first." 4) "Bathe the patient from head-to-toe, cleanest areas first."

ANS: 4

15. Wearing poorly fitting shoes may result in which condition? 1) Tinea pedis 2) Plantar wart 3) Excoriation 4) Ingrown toenail

ANS: 4

17. Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? 1) 99°F (37.2°C) 2) 102°F (38.9°C) 3) 103°F (39.4°C) 4) 105°F (40.6°C)

ANS: 4

19. A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1) Dryness of the mouth 2) Bitter taste 3) Demineralization of the tooth enamel 4) Gingival hyperplasia

ANS: 4

20. The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if the patient is placed in which position? 1) Supine 2) Prone 3) Semi-Fowler's 4) Side-lying

ANS: 4

4. Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care

ANS: 4