Fundamentals Exam 1 (chapter 30 Hygiene)

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes

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 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."

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.

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 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."

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."

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?"

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 statements from the students indicate 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 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 nurse is preparing to provide hygiene for a client with obesity who has bedrest ordered for 3 days. What is the priority nursing intervention that will be performed to deliver hygiene care?

Check order within the plan of care for hygiene.

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 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.

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.

A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which clients are most susceptible to nail problems?

Clients with diabetes

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.

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 of the following actions will she perform?

Create a calming environment with little stimuli.

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.

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.

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.

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.

A nurse is making an unoccupied bed for a hospitalized patient. 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, forming a corner according to agency policy.

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 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

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 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

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.

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 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 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

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

Periodontitis

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. Arrange for suctioning to remove mucus. Assist the client to a lateral position.

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.

When performing health education regarding hygiene, the nurse should advise female clients to avoid the use of which of the following? Select all that apply.

Routine douching Vaginal deodorants

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.

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

Sitz bath

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.

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

Store the hearing aid in cool environment.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, the nurse understands the importance of what type of positioning to decrease complications of oral care?

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

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 client who is on warfarin therapy. Which teaching will the nurse provide?

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 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.

What should the nurse do to prepare the unconscious client for oral care?

Use small amounts of water and oral suction device.

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

alopecia

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

assess the client's safety.

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 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.

The nurse is caring for a client who has a fungal infection in the groin. The client reports feeling sore and itchy. Upon assessment, the nurse notes a cluster of vesicles that are scaly and cracked. What tinea condition does the nurse anticipate?

cruris

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

how often the client is bathing.

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 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