CHAPTER 31 PREP U

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." Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratoses and this doesn't address the client's concern of brown patches on their face and arms.

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

51-year old with hemorrhoids A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. The other clients do not get as much benefit from this type of bath.

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." Psoriasis is a noninfectious chronic skin disorder that appears as elevated silvery scales that shed over elbows, knees, trunk, and scalp. Acute episodes occur between periods of relief. The nurse will educate that the client should be wary of advertised remedies that promise a cure or quick relief, since this condition can be managed, but not cured. The nurse will not tell the client that the medication prescribed by the health care provider will be a cure, encourage the client to use the remedy, or provide false hope of the condition being cured.

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?

"I will set up your bath for you. I will come back and help you with your bath." The nurse must value and support the client becoming independent in care.

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." Gloves should always be used to remove an unconscious client's dentures. Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth so the gum lines do not begin to change. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.

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." When making an occupied bed, it is important for the nurse to use clean linen and make the near side of the bed first. Then, the nurse places the bottom sheet in the center of the bed. Next, the nurse opens the sheet and pulls the bottom sheet over the corners at the head and foot of the mattress. Next, the nurse pushes the sheet toward the center of the bed, pulling it taut and positioning it under the old linens to avoid contaminating the new linen. In the image, the position of the client is for making an occupied bed, not for assessing the skin as the old linen is covering the client's skin. The nurse is not tucking the draw sheet tightly; it is the fitted (bottom) sheet that is displayed in the image.

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." Soap should not be used on a daily basis since it can have a very drying effect on the skin. Therefore, the nurse should re-educate the family on this information. Thus, the family should check the temperature of bath water before immersing an older adult client because with aging there is a diminished ability to sense temperature changes. Grab bars and shower chairs are a safety measure to assist the client in and out of the tub or shower.

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 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." 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.

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." When plaque remains on the teeth, it hardens into tartar, which cannot be removed by simple brushing; a professional must scrape it off with dental instruments. Fluoride in small amounts strengthens teeth during their formation and helps prevent caries. Fluoride is added to most water-treatment systems at the appropriate concentration of 1 part per million. Adult caregivers may want to ask their dentist how to give children appropriate supplements of fluoride until the age of 14 if their water system is not fluoridated.

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." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin." 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 6 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.

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?

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

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 client needs his or her hair washed to prevent infection and to promote adequate hygiene. The nurse should ask the client about usual personal hygiene practices and documents the client's responses. This will help the nurse determine the client's hair hygiene routine and how it can be used in the hospital setting. The questions should be open-ended and nonthreatening. Asking why the client does not want the nurse to wash the hair may make the client respond in a defensive manner. The other responses are not open-ended and are better suited as follow-up questions. This approach should help the client work through possible concerns or barriers.

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." Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratosis, as these spots are raised in appearance. The spots are not likely cancer and do not need to be removed.

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?

"What are your expectations about bathing at this time?" In order to assess this client's normal pattern of self-care while on her medications, it is important to assess what her expectations are. Once these expectations are established, the nurse can work with the client to achieve them.

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." "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 hospital can be a stressful environment for clients. It is important to provide an environment of comfort and ensure the client has everything he or she needs while in the hospital. Asking the client if he or she needs anything before leaving the room demonstrates caring and increases safety by decreasing the risk of falls when client gets out of bed independently. Ensure good ventilation and clean room environments by removing unpleasant odors and using room deodorizers that are not offensive. Keep the room comfortable for the client. Avoid behaviors that will limit sleep or cause concern to the client, such as loud noises, interrupting the client several times daily for procedures, and discussing information outside a client's room.

A sitz bath would be most appropriate for which client?

33-year-old who is one day postpartum A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. The client who has given birth would benefit from this type of cleansing treatment. The other clients do not benefit as much, or at all, from the sitz bath.

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 full bed bath every day may cause excessive dryness in many older adults, and a continent client may not require a bath every day. If dry skin is a problem, water and skin lotion or bath oil may be used on alternate days with a bed bath. Do not use bath oil in tub water, as it can cause tub surfaces to become slippery. Bed baths should not be avoided altogether but simply given every other day.

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. 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.

A client has a nasogastric tube following abdominal surgery. Which intervention(s) does the nurse perform to prevent an alteration in the client's oral health? Select all that apply.

Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours o prevent an alteration in the client's oral health, the nurse applies lubricant to the lips and nostrils of the client. The nurse offers water or mouthwash to rinse the mouth every hour. The nurse also encourages the client to swallow saliva naturally and assists the client to brush teeth at least every 4 hours. Assisting the client to brush the teeth at least once every day is not frequently enough to maintain optimal oral care for the client with a nasogastric tube. Lemon glycerine swabs and other alcohol-based mouthwashes and products are drying agents and should not be used.

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. Upon noting the history of contact lenses, it would be most appropriate to assess both eyes for the presence of contact lenses. Some people wear contacts in only one eye. Removal of contact lenses may be delegated to the UAP, but only after proper assessment by the nurse. Contacting the client's caregiver would not provide the nurse with the needed information. The health care provider does not need to be contacted unless an injury is present.

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. Gentle pressure should be used to center hard or gas-permeable lenses on the cornea. Once removed, lenses should be placed in the appropriate container, identifying the right and left lenses. If an eye injury is present, the lenses should not be removed because of the danger of causing an additional injury. If the lenses cannot be removed easily, they should be removed with the appropriate tool designated for the type of lenses in place.

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 Clients with diabetes will be more susceptible to infection from breaks in skin integrity and nail problems. People with diabetes are more susceptible to fungal toenails and foot injury because of poor circulation and lack of feeling. A bunion, a bony bump on the joint at the base of the big toe, is not specific to clients with diabetes and can be caused by wearing tight, narrow shoes. Cold feet can be caused by things other than diabetes, such as atherosclerosis. Red inflamed joint of the big toe with reports of pain can indicate the client is suffering from gout and may not be attributable to diabetes.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures Brushing the dentures is within the scope of practice for the UAP and therefore it is appropriate to delegate this aspect of denture care. Assessment, planning, and teaching fall within the scope of practice for the nurse and are not appropriate for delegation to the UAP.

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?

Corn This describes a corn. A callus is a flattened thickening of epidermis which is often found on the bottom or side of the foot, over a bony prominence. A plantar wart is a round or irregular area that is flattened by pressure and is surrounded by cornified epithelium. A bunion is an inflammation and thickening of bursa at the great toe joint which causes an enlargement of the joint and a displacement of the toe.

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. The nurse can ensure the client's safety by checking for nonskid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs, as they increase the risk of falls.

A school nurse assesses children in the third grade for pediculosis capitis. Which information is communicated to parents to manage the situation and prevent its spread? Select all that apply.

Check your children's hair for head lice on a weekly basis. The treatment is permethrin 1% lotion which you will apply to the scalp and hair. Nits are white or light grey and look like dandruff, but you will not be able to brush or shake them off the hair. Notify the school and the parents of close friends if you identify head lice in your children. Parents should be told to check their children's hair for head lice on a weekly basis. The usual over-the-counter treatment for pediculosis capitis is permethrin 1% lotion that is applied to the scalp and hair, left in place for 10 minutes, and then rinsed out. The treatment is repeated 7 days later. Nits are white or light grey and look like dandruff, but they cannot be brushed or shaken off the hair. Parents are asked to notify the school and the parents of close friends if they have identified head lice in their children, so that if the lice were transmitted, treatment can start as soon as possible. Treatment is to be repeated 7 days after initial treatment, not every 3 days.

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. Clients who have diabetes, impaired circulation, or thick nails are at risk for vascular complications secondary to trauma. The services of a podiatrist should be obtained. It is not appropriate to clip the toenails with large clippers, use a handheld electric rotary file, or clean under the toenails with a wooden orange stick.

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

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

Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Other items listed are inappropriate for teaching.

Gloves should be worn while changing a client's bedding, but a gown is not normally necessary unless the client was on contact precautions. The chain of infection underlies these directives, but the immediate priority is changing the UAP's behavior. Changing a bed can safely be done alone.

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 should warm the unopened package in the microwave, according to the manufacturer's directions. The other methods are not as effective or efficient.

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 The assessment points to gingivitis. Gingivitis is a condition in which there is inflammation of the gums that bleed easily when the person brushes the teeth. This condition can be fixed with longer and more frequent brushing and flossing. Knowing how often the client brushes and flosses the teeth will help determine if the cause is from dental plaque from poor oral hygiene or another cause. Knowing the history of oral surgery and cavities or how often the client sees the dentist is important, but it is not helpful in determining next steps related to the finding.

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. Ideally, the client should brush the teeth after eating or drinking to help prevent tooth decay; if not able to brush, rinsing is beneficial. Automatic toothbrushes are acceptable for removing debris and plaque from teeth. Salt and sodium bicarbonate should only be used for short-term use in place of toothpaste because they lack fluoride. Soft toothbrushes prevent injury to the gums. The tongue should be brushed to decrease bacterial growth and halitosis. Water spray units can help remove debris from the oral cavity.

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?

Independent showering Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowing the client to shower independently would be appropriate. The client is not unstable enough to prohibit hygiene measures.

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. Extra batteries should be kept in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.

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. Keeping hair off the face and washing the hair daily will help prevent oil from transferring from the hair to the skin, causing clogged pores. The client should avoid squeezing or picking infected areas because this can spread the infection and cause scarring. The adolescent should be taught to gently wash the face twice a day with a mild cleanser and warm (not hot) water.

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. Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.

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. When dentures are left out for long periods of time the client's gum lines may change, causing the dentures to fit poorly. Dentures should always be kept in a denture cup with cold water to prevent the dentures from drying out and cracking or warping. A soft toothbrush and toothpaste with lukewarm water for rinsing should be used to clean dentures.

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.

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. Preschool and elementary age students are at greatest risk for contracting head lice. However, anyone can contract head lice at any time regardless of hygiene measures or socioeconomic class. Head lice are transmitted during close hair-to-hair contact during play, sports, on the playground, at slumber parties, or at camp. These are all activities of these age groups. Sharing close personal items also puts them at risk for contracting head lice. Head lice are best detected at night in the dark when they are most active.

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

No nail treatments can be utilized. Clean under the fingernails when washing hands. Fungal nail infections can result from application of artificial fingernails, whether acrylic or gel. No type of nail treatment or polish should be used. The nurse should wash hands frequently, cleaning under nails each time to prevent transmission of infection.

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 Contact lenses are most commonly stored in normal saline. Sterile water contains water that is sterilized and packaged for use as an irrigant. A hypertonic solution is a particular type of solution that has a greater concentration of solutes on the outside of a cell when compared with the inside of a cell (e.g., 3% saline). A hypotonic solution is any solution that has a lower osmotic pressure than another solution (e.g., 0.45% saline).

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. To remove an artificial eye, pull down on the lower eyelid and exert slight pressure below the eyelid; this will overcome the suction holding the eye in place.

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. The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.

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. Proper bed height helps reduce back strain while performing the procedure. A protective pad keeps the sheets from getting wet. Placing a drain container under the shampoo board prevents a mess on the floor. Closing the curtains around the bed and closing the door to the room provides for client privacy.

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. Fungal nail infections can result from application of artificial fingernails if unsanitary application utensils are used. The nurse manager will educate the nurse on outcomes associated with use of artificial nails, refer the nurse to the agency policy on wearing artificial nails, and provide the nurse with literature that demonstrates outcomes of appropriate hand hygiene. Demanding that the nurse remove the artificial fingernails immediately does not educate the nurse and can contribute to a hostile working relationship. The agency policy may prohibit nurses from wearing any fingernail treatment, so polish should not be recommended.

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. Remove and discard the shampoo cap after a single use and dry the client's hair with a towel. Caps may be safely warmed in a microwave oven. A towel should be placed around the client's shoulders before placing the cap on his or her head. There is no need to wait 5 minutes before massaging the client's scalp.

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.

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 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.

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. The nurse should encourage the client to wear the dentures, if not contraindicated. Dentures enhance appearance, assist with eating, facilitate speech, and maintain the gum line. Denture fit may be altered if dentures are not used for long stretches. The nurse should encourage the client to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. In addition, the nurse should encourage the client to refrain from placing the dentures in the bed clothes because they can be lost in the laundry. The client should store dentures in cold water when not in the mouth. Leaving dentures dry can cause warping, leading to discomfort when worn.

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

Store the hearing aid in a cool environment. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Other items listed are inappropriate for teaching.

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 A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.

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. 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. In others, the use of these products may be contraindicated due to personal or cultural values. Independence with hygiene measures is encouraged and cosmetics may be used for multiple reasons, including self-image enhancement in women. There are several bath preparations and a bag bath is convenient and beneficial to the client's skin.

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. Eroding the tooth enamel can cause dental caries (cavities). Tartar (hardened plaque) is more difficult to remove and may lead to gingivitis (inflammation of the gums). Pockets of gum inflammation promote periodontal disease, a condition that results in the destruction of the tooth-supporting structures and bones that make up the jaw.

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. When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.

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. Clients who are not alert are at risk for aspirating liquid into their lungs. Aspirated fluids predispose a client to pneumonia. The nurse should use special precautions to avoid getting fluid into the client's airways and lungs. Position the client on the side with the head slightly lowered. An upright position will not protect the airway from fluids entering. The lithotomy position is used for vaginal and anal exams and will not protect the airway from fluids and aspiration.

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. Tepid baths will most likely help relieve inflammation and itching. The area should be washed thoroughly with a mild cleansing agent and rinsed well. Over-the-counter products can be used on unknown rashes if approved by the health care provider. A moisturizing lotion is recommended to use on a dry rash, and a drying agent on a wet rash, to prevent itching and promote healing.

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 Several considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using nonskid mats and using a tub/shower seat. Also, care is taken to promote independence by providing the client with long-handled shower brushes or attachments if there is limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. The nurse should use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. The nurse should avoid using perfumed soaps and lotions, as well as avoid rubbing the skin when drying. The nurse should use gentle patting motions to maintain skin integrity.

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

Use an electric razor for shaving purposes. Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, in place of a safety razor, and a soft-bristled toothbrush will reduce bleeding during care of skin and gums. The client should not be advised to take aspirin, buy a hard-bristled toothbrush, or explain that prolonged bleeding is normal.

Which modification 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. Povidone-iodine, also known as iodopovidone, is an antiseptic used for skin disinfection before and after surgery. It may be used both to disinfect the skin of the client and the hands of the health care provider, but is not used as a bathing agent. The client should be cleaned daily as this will not preserve skin integrity. A complete bath is not necessary each time a client has an episode of incontinence because this can dry out the skin and put the client as risk for an infection by decreasing the skin flora.

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 contact lens that presents a challenging removal should be addressed by the nurse rather than delegated to UAP. This is due to the potential for injury to the resident's eye. All of the other listed tasks can be safely delegated to UAP.

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

When inserting an endotracheal tube If the client is brought to the hospital with a full beard, do not shave his beard without consent unless it is an emergency situation, such as insertion of an endotracheal tube. For this procedure, shave only the area needed and leave the rest of the beard. A nebulizer can be used effectively with a beard in place and a tangled beard can usually be untangled.

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. Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care.

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. Shampooing removes dirt and oil from the hair and scalp. Clean hair makes clients feel good about their appearance and enhances feelings of self-worth.

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

how often the client is bathing. Frequent bathing for the older client can dry skin and contribute to skin breakdown.

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 will remove toast, which is a carbohydrate, and jelly, which is a sugar, from the client's tray. Other food items are acceptable for the client to eat.

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) 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. Although it is important to assess cultural views related to shaving, the client is asking to shave, so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.

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 When shaving a client, it is appropriate to wash the skin prior to shaving and to rinse the razor after each stroke. It is also appropriate to apply direct pressure if the skin is nicked from the razor. It is not appropriate to shave against the direction of hair growth. Shaving with the direction of the hair reduces the potential for irritation of the skin.

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 sitz bath washes the pelvic area with warm water and can help to decrease inflammation after birth.

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 Pediculosis is an infestation of the hairy parts of the body or clothing with the eggs, larvae or adults of lice. The crawling stages of this insect feed on human blood, which can result in severe itching. When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the client will shampoo the hair once and not follow through with a second washing. Pediculosis requires treatment which is combing out the nits or egss and is not self-limiting. Pediculosis is not a reflection of inadequate hygiene. It is also not necessary to destroy the child's clothing and bedding.

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. Fluoride strengthens teeth during their formation and helps prevent dental caries. Children need both milk and water. There is no reason for alternation between tap and bottled water if the bottled source has adequate flouride.

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 A traditional bed bath with linen change provides the greatest opportunity for full cleansing. The client is unable to perform assistance with a shower, and is not a candidate for a bed bath. Although a bag bath may be useful, the traditional bed bath with linen change provides the best opportunity for infection control in observance of the mild skin breakdown that has been noted.

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 Skinfold areas may be sources of odor and skin breakdown if not cleaned and dried properly. The antecubital fossa (inner portion of arm) and popliteal space (behind the knee) are not skinfold areas that require cleaning. The eyes, toenails, and fingernails are not sources of odor.

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. Preferences for hygiene vary widely among individuals and across cultures.

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 Gloves should always be used to remove an unconscious client's dentures. Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth so the gum lines do not begin to change. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.