Chapter 31 - More Practice Questions

A homeless person uses the soap and towels in a public restroom to wash up. This is an example of which type of factor affecting personal hygiene practices? A) Socioeconomic class B) Culture C) Developmental level D) Health state

A Feedback: A person's socioeconomic class and financial resources often define the hygiene options available to him or her. Access to assistive services, such as shelters, may be limited for some clients. For example, homeless people, who often carry all their belongings in a car or shopping cart, may welcome the warm running water and soap available in roadside or public restrooms.

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? A) From the pubic area toward the anal area B) From the anal area to the pubic area C) From side to side within the labia D) The direction does not make any difference

A Feedback: Always proceed from the least contaminated area to the most contaminated area. For a female client, spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over to the genital area.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following actions is correct? A) Remove the antiembolism stockings during the bath. B) Leave the antiembolism stockings in place, but be sure to remove all wrinkles. C) Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse. D) Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.

A Feedback: Antiembolism stockings should be removed periodically to allow for assessment.

A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care? A) Use an antifungal powder on the client's feet if necessary. B) Carefully remove any corns or calluses that are present. C) Soak the client's feet for 15 to 20 minutes prior to cleansing. D) Avoid using soaps or commercial cleansers whenever possible.

A Feedback: Antifungal foot powders may be used when indicated, and it is appropriate to use soap and/or cleansers when providing foot care. Corns and calluses should not be removed, and the nurse should avoid soaking the client's feet.

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following? A) Facilitates oil distribution B) Cleans hair and scalp C) Removes excess oil D) Cleans the hair of dirt

A Feedback: Brushing the hair facilitates oil distribution along the hair shaft more effectively than combing, as well as massages the scalp and stimulates circulation. Shampooing cleans the hair and scalp, helps get rid of excess oil, and cleans the hair of dirt. It provides a relaxing, soothing experience for the client.

The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care? A) Apply moisture barriers to the skin of the perineal area. B) Provide excessive hydration to the skin of the perineal area. C) Wash the perineal area frequently with soap and water. D) Aggressively cleanse the perineal area with a washcloth or towel.

A Feedback: Care to the perineal area for an incontinent client includes the use of moisture barriers, skin cleansers, and moisturizers and the avoidance of soap or friction. Measures should be followed to reduce overhydration because this will increase the risk for perineal damage and skin breakdown.

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene? A) Provide the client with an electric shaver. B) Provide the client with a firm bristled toothbrush. C) Do not allow the client to shower. D) Avoid massaging the client's back with lotion.

A Feedback: Electric shavers are recommended when a client is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the client is more prone to bleeding, and the firm bristles may lead to bleeding. The client should be allowed to shower, unless there are other contraindications. A back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct? A) Inform the client that baby powder is not used because it may become a medium for bacterial growth. B) Carefully apply baby powder to skin folds only. C) Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder. D) Apply a generous amount of baby powder to all areas where skin touches skin.

A Feedback: Failing to pull the foreskin back into place may cause tissue damage to the penis.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct? A) Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. B) Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position. C) Avoid retraction of the foreskin because injury and scarring could occur. D) Soak the end of the penis in warm water before cleaning the shaft of the penis.

A Feedback: Failing to pull the foreskin back into place may cause tissue damage to the penis.

Which client is most likely to require hospitalization related to problems associated with the feet? A) A client with peripheral vascular disease B) A client with osteoporosis C) A client with asthma D) A client with diabetes insipidus

A Feedback: Foot problems, particularly common in people with diabetes and peripheral vascular disease, often require hospitalization.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A) Partial care B) As-needed care C) Self-care D) Complete care

A Feedback: Morning care is categorized as self-care, partial care, or complete care. Clients identified as partial care most often receive morning care at the bedside, or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach. Clients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. Clients identified as complete care require nursing assistance with all aspects of personal hygiene. In additional to scheduled care, the nurse will offer care as needed.

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? A) Periodontitis B) Plaque C) Halitosis D) Caries

A Feedback: Periodontitis is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; and loose teeth.

An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? A) Use a nonsoap cleaning agent. B) Use organic soap and shampoo. C) Bathe the client more often, but without using soap or shampoo. D) Provide the client with bed baths rather than tub baths.

A Feedback: Soap cleans the skin, but while it removes dirt from the surface, it affects the lipids that are present on the skin, and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. The substitution of a nonsoap, emollient cleaning agent is an easy way to prevent drying and damage to the skin. An organic soap is not necessarily less drying to the skin. It would be inappropriate to forego the use of any cleaning products whatsoever. Providing a bed bath rather than a tub bath will not necessarily minimize dry skin.

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? A) Wash hair daily B) Use dry shampoo C) Use oil-based shampoo D) Use anti-lice shampoo

A Feedback: The client with a scalp infection should be advised to shampoo her hair daily with a mild shampoo. For occasional use, the nurse will use dry shampoos, which are applied to the hair as a powder. Other options include aerosol spray or foam. Anti-lice shampoos or oil-based shampoos are not used for fear of aggravating the infection.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine.

A Feedback: To ensure proper perineal care, the nurse should cleanse to remove secretions and excretions from less-soiled to more soiled areas. The nurse must also prevent direct contact with and any secretions or excretions by wearing clean gloves. The nurse should not use cotton cloth or tissues to clean the perineal area because that might lead to skin impairment. Older adult clients have sensitive skin, which may be easily impaired when cleaning. Because the client cannot do anything independently, providing him with a bed pan or a jar will not help.

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? A) "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." B) "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." C) "Client bathes more often than necessary and consequently experiences dry skin." D) "Client's level of personal hygiene is acceptable and age-appropriate."

A Feedback: When documenting the nursing history, it is best to be specific, clearly describing the client's typical hygiene practices and any complaints. Judgments regarding cause and effect are likely premature in this context and may be inaccurate.

Which of the following clients ia at an increased risk for oral problems? Select all that apply. A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client

A, B, C, D Feedback: Clients at increased risk for oral problems include those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed. Clients who are mouth breathers, those who can have no oral intake of nutrition or fluids, those with nasogastric tubes or oral airways in place, and those who have had oral surgery are also at increased risk. Variables known to cause oral problems include deficient self-care abilities, poor nutrition or excessive intake of refined sugars, family history of periodontal disease, or ingestion of chemotherapeutic agents that produce oral lesions.

What care should the nurse take when providing foot care for a client with peripheral vascular disease? Select all that apply. A) Use an emery board to file toe nail edges B) Cut the toenails short C) Cut the nail in one piece D) Avoid cutting into calluses E) Cut the nails straight across

A, D, E Feedback: The nurse caring for the client with peripheral vascular disease should use an emery board to file nail edges. These clients may have thick distorted nails that may be difficult to cut, but can be safely filed. The nurse should avoid cutting the nails too short or cutting into calluses to prevent trauma. The nurse should cut the nails straight across if possible, and cut in a few small pieces rather than one piece to prevent injury or skin breakdown.

Which client would be most at risk for alterations in oral health? A) Infant who is breast-fed B) Man with a nasogastric tube C) Woman who is pregnant D) Healthy young adult

B Feedback: A variety of illnesses and habits may increase the risk for oral health problems, including poor nutrition, treatment with chemotherapy, those who are NPO, and those who have nasogastric tubes or oral airways in place.

Which of the following is a correct guideline to follow when providing a bed bath for a client? A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.

B Feedback: Fold the washcloth like a mitt on your hand so that there are no loose ends. Moving from the inner to the outer aspect of the eye prevents carrying debris toward the nasolacrimal duct. The gluteal area should be cleaned first and the bath water and towels should be changed before cleaning the perineal area. It is not necessary to change the bath water after washing every body part.

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? A) The pubic area for growth of hair B) The head for nits on hair shafts C) The nails for evidence of cleanliness D) The body for evidence of abuse

B Feedback: Infestation with lice is called pediculosis. Pediculosis capitis infests the hair and scalp. Lice lay eggs, called nits, on the hair shafts. Nits are white or light gray and look like dandruff, but cannot be brushed or shaken off the hair.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? A) Remove ingrown toenails B) Cut the nail straight across C) Protect the foot from blisters D) Soak the foot in witch hazel

B Feedback: The feet of older adults require special attention, because foot problems may relate to reduced peripheral blood flow. Poor circulation makes the feet more vulnerable to infection and skin breakdown, particularly after trauma. By cutting the nail straight across, the nurse can protect the toes from trauma.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what? A) Allow the client privacy B) Assess the client's safety C) Assess the client's pain D) Allow sufficient time

B Feedback: Toileting often is associated with falls; the nurse must ensure the client's safety.

A nurse is providing oral care to a client with dentures. What action would the nurse do first? A) Assess the mouth and gums. B) Don gloves. C) Wash the client's face. D) Apply lubricant.

B Feedback: When providing oral care and denture care, the nurse would be exposed to body fluids. The nurse should always don gloves if exposure to body fluids will occur.

Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? A) None; they should be placed in saline B) To increase comfort when replaced in the mouth C) To prevent drying and warping of plastic D) To ensure the dentures are not thrown away

C Feedback: If a client removes dentures while sleeping, they should be stored in water in a disposable denture cup to prevent drying and warping of plastic materials.

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? A) Yes, this helps prevent vaginal odor. B) Yes, this decreases vaginal secretions. C) No, douching removes normal bacteria. D) No, douching may increase secretions.

C Feedback: In normal healthy women, daily douching is believed to be unnecessary because it removes normal bacterial flora from the vagina. Douching has been linked to bacterial vaginosis, pelvic inflammatory disease, higher rates of HIV transmission, tubal pregnancies, chlamydial infection, and cervical cancer.

The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? A) "That's not good. Use a Q-tip or your finger instead." B) "You really like to keep your child clean. Good for you!" C) "That is dangerous; you might puncture the eardrum." D) "Show me exactly how you use the hairpin."

C Feedback: Little intervention is needed for routine hygiene of the ear. Using bobby pins, hairpins, paper clips, or fingernails to remove wax from the ear is extremely dangerous because these may injure or puncture the eardrum.

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes

C Feedback: Steps in the procedure include: Cover patient's chest with a towel or waterproof pad. Fill bath basin with warm (43ºC to 46ºC [110ºF to 115ºF]) water. Put on gloves. Moisten the area to be shaved with a washcloth. Dispense shaving cream into palm of hand. Apply cream to area to be shaved in a layer about 1/2-inch thick. With one hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin shaving. If shaving the face, shave with the direction of hair growth in downward, short strokes. If shaving a leg, shave against the hair in upward, short strokes. If shaving an underarm, pull skin taut and use short, upward strokes.

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene? A) "Perhaps you don't recognize your bad body odor." B) "You must eat a lot of greasy foods to have this acne." C) "Tell me about what you do to take care of your skin." D) "Why do you only take a bath once a week?"

C Feedback: When skin problems are present, the nurse asks the client about usual personal hygiene practices and documents the client's responses. The questions should be open-ended and nonthreatening.

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas.

D Feedback: Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

Which of the following factors does not affect personal hygiene practices? A) Culture B) Income level C) Health state D) Gender

D Feedback: Personal hygiene practices vary widely among individuals and are affected by culture, socioeconomic status, spiritual practices, developmental level, health state, and personal preferences.

Which clent would be at greatest risk for injury to the skin and mucous membranes? A) Infant 10 days old with no health problems B) adolescent 17 years of age with asthma C) Man 44 years of age with hemorrhoids D) Man 77 years of age with diabetes

D Feedback: Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissue, and illness conditions. In this question, the older man with diabetes would be most at risk.

A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care? A) Middle-aged man with a nasogastric tube B) Young adult man who has had a hernia repair C) Young woman who has had cosmetic surgery D) Middle-age woman with a Foley catheter

D Feedback: The dark, warm, moist perineal and vaginal areas favor bacterial growth. Variables known to create a need for special care include an indwelling Foley catheter. The client who cannot clean the perineal area needs the nurse's assistance for personal hygiene.

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of the following would the nurse expect to find in the client? A) Diffuse scaling of the epidermis B) Itching and flaking of whitish scales C) Premature loss of hair D) Inflammation related to bites along the hairline

D Feedback: The nurse would find inflamed bites along the hairline in the client with pediculosis infestation. Diffuse scaling of the epidermis with itching and flaking of whitish scales is seen in clients who have dandruff. Hair loss is not a manifestation of pediculosis capitis.

What type of bath is preferred to decrease the inflammation after rectal surgery? A) Bed bath B) Tub bath C) Whirlpool bath D) Sitz bath

Feedback: A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.