Hygiene

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

51-year old with hemorrhoids

Bunion

swelling of the joint at the base of the great toe caused by inflammation of the bursa

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

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.

senile lentigines (liver spots)

flat brown macules, benign variant of aging

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?

"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."

Corn

- cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint

Callus

- flattened thickening of epidermis which is often found on the bottom or side of the foot, over a bony prominence.

plantar warts

- round or irregular area that is flattened by pressure and is surrounded by cornified epithelium.

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.

Which intervention(s) does the nurse initiate to assist a client in preventing corns on the feet?

Client will wear shoes that have extra padding Client will wear shoes that are not tight around the toes Client will wear clean, dry socks

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.

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 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 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.

At Risk for Skin Alteration

Lifestyle factors Changes in health state Illness Diagnostic measures Therapeutic measures

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.

Which information does the nurse teach the client who just received the first pair of dentures?

Rinse the mouth before reinserting the dentures Use a brushing technique similar to that for natural teeth Use soap and water or a mild commercial cleaning agent Store dentures in water in a covered container when not being worn

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 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 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)

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