Chapter 32: Hygiene

The nurse is caring for a client who informs the nurse that they need assistance to remove and clean their prosthetic eye. What action by the nurse is appropriate to accomplish the task?

33-year-old who is one day postpartum

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

51-year old with hemorrhoids

A nurse is assisting a client who has decreased range of motion with their bed bath. The client states, "I can do it myself." How will the nurse respond?

"I will set up your bath for you, and you can use the call button to let me know if you need help."

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."

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

An older adult client is reporting dry, itching skin. In addition to skin inspection, what assessment will the home care nurse perform?

determining how often the client is bathing

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that:

hair should be washed as often as necessary

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What question would the nurse ask to assess for complications or side effects of chemotherapy?

"Have your mouth and lips become sore and inflamed with ulcers?"

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 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 linens 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."

The parents of three 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 8, 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." "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 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."

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?"

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 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.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care?

Assist the client in dressing oneself after offering alternative techniques

An older adult client recently suffered a stroke. The client is bedbound from the resultant paralysis of the right arm and right leg. Which intervention by the nurse is the best strategy to maintain skin integrity?

Avoid hot water during bathing.

The nurse is caring for a client with conjunctivitis and is assisting the client with eye care. What is the nurse's most appropriate action?

Cleanse each eye with a separate washcloth.

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.

A nurse is providing oral care to a client and observes that a significant amount of blood is coming from the client's gums. Which actions are appropriate responses? Select all that apply.

Encourage the client to rinse his or her mouth and spit. Check the client's most recent platelet level after providing care.

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.

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

File, rather than cut the nails.

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 is hospitalized with uncontrolled diabetes. Which action(s) does the nurse take to promote circulation and prevent circulatory complications? Select all that apply.

Inspect the client's feet daily. Clean the feet daily with warm water and a mild soap. Cut the toenails straight across and file the edges with an emery board.

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.

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 performs personal hygiene, including bathing, for an immobile client. What benefit(s) is the client gaining? Select all that apply.

Promotes relaxation and comfort Increases circulation Helps maintain muscle tone and joint mobility Reduces the risk of acquiring multidrug-resistant organisms

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

Providing a back rub before bed

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 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.

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 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.

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 nurse is providing care for a client and observes that their eyeglasses are cloudy and soiled. Which action would the nurse take to be sure the lenses are clean and not damaged during cleaning?

Use a special cleaning solution for eyeglass 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.

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.

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.

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?

Use bath oil in the tub to decrease dry skin.

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.

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

Use special perineal skin cleaners and moisture barriers.

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

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

When inserting an endotracheal tube.

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.

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 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.

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

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)

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?

nerve

The nurse is admitting a new older adult client who uses hearing aids. When caring for the client's hearing aids, the nurse would:

place the hearing aids in a closed, labeled container when not in use.

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply.

prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count

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 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