Hygiene - Sherpath Lessons

Which is a correctly stated hygiene and personal care long-term goal statement? A. Patient will shower independently by the end of one month. B. Self-care deficit will be resolved within three to six days. C. Uses toothbrush to perform oral hygiene without assistance. D. Within 24 hours, patient will bathe with the help of one person.

A. Patient will shower independently by the end of one month.

The nurse is caring for a patient who was involved in a motor vehicle accident (MVA). The patient did not sustain any oral trauma. How should the nurse document the normal assessment of this patient's oral cavity? A. Pink and moist oral cavity without sores B. Red and dry oral cavity without sores C. Pink and dry oral cavity without sores D. Cyanotic and moist oral cavity without sores

A. Pink and moist oral cavity without sores

A nurse is performing an initial assessment on a recently admitted patient. What finding warrants an immediate call to the healthcare provider? A. Presence of pediculosis B. Halitosis related to poor oral hygiene C. Oily, matted, and tangled hair D. Warm, moist, and intact skin

A. Presence of pediculosis

Which factors should the nurse consider when developing an individualized care plan for a patient's hygienic and self-care needs? (select all that apply) A. Present capabilities B. Supportive resources C. Available lift equipment D. Family involvement E. Personal care supplies

A. Present capabilities B. Supportive resources D. Family involvement E. Personal care supplies

Which activity does the nurse perform when planning for a patient's hygiene and personal care? (select all that apply) A. Prioritizes patient's hygiene-related nursing diagnoses B. Sets realistic personal care goals with the patient C. Assesses patient's hygiene and self-care abilities D. Measures achievement of patient's hygiene outcomes E. Assesses the patient's home environment

A. Prioritizes patient's hygiene-related nursing diagnoses B. Sets realistic personal care goals with the patient

A nurse is reviewing personal care procedures with nursing students. The nurse knows they understand the importance of hygiene when they make which statement? A. "Personal care should be delegated to unlicensed personnel." B. "Personal care is the best time to perform a skin assessment." C. "Personal care is not a priority and should be done if the nurse has time." D. "Personal care must be done before any other direct care is performed."

B. "Personal care is the best time to perform a skin assessment."

Nursing diagnoses related to hygiene and personal care are selected after which important activity? A. Implementing bathing and grooming protocols B. Assessing patient self-care abilities C. Collaborating with nursing team members D. Setting realistic short-term patient goals

B. Assessing patient self-care abilities

The nurse finds a patient to have missing teeth and refusing to wear dentures. Which food items should the nurse advise the patient to eat? (select all that apply) A. Steak B. Banana C. Gelatin D. Applesauce E. Apple

B. Banana C. Gelatin D. Applesauce

The nurse is caring for a patient who had a stroke that left him completely paralyzed. The patient is edentulous. How should mouth care be performed on this patient? A. Clean the mouth with a toothbrush and toothpaste. B. Clean the mouth with mouth swabs. C. Clean the mouth with peroxide mouth rinse. D. It is not safe to clean the patient's mouth because of the stroke.

B. Clean the mouth with mouth swabs.

Which nursing diagnosis best displays sensitivity towards the needs of the patient and family? A. Risk for falling B. Compromised family coping C. Ineffective activity planning D. Compromised breathing

B. Compromised family coping

What contributes to an older adult patient's skin being wrinkled, thin, and dry? A. Increased number of infections B. Decreased elastin C. Decreased varicose veins D. Increase in subcutaneous fat

B. Decreased elastin

The nurse delegated several patient tasks to UAPs on a nursing unit. Who is ultimately responsible for delegated tasks? A. UAPs performing tasks B. Delegating nurse C. Charge nurse D. Nursing supervisor

B. Delegating nurse

A patient arrives at the emergency room with a puncture wound. What type of injury best describes a puncture wound? A. Paper cut B. Dog bite C. Popped blister D. Black eye

B. Dog bite

What are the benefits of interventions related to good hygienic practices? (select all that apply) A. Educating the patient on medications B. Improving the patient's self-image C. Educating the patient on complications of a procedure D. Improving nurse-patient communication during the therapeutic process E. Improving the patient's compliance with medical treatment

B. Improving the patient's self-image D. Improving nurse-patient communication during the therapeutic process

Which action by the nurse indicates a collaborative approach to improving a patient's ability to perform self-hygiene and personal care? A. Assigning the UAP to comb the patient's hair B. Partnering with the occupational therapist C. Asking the family to care for the patient's needs D. Reporting on patient needs to the oncoming nurse

B. Partnering with the occupational therapist

A patient is unable to perform self-care activities. Following collaboration with the UAP, which activities can be delegated? (select all that apply) A. Wound care B. Personal grooming C. Partial bath D. Denture care E. Hair care

B. Personal grooming C. Partial bath D. Denture care E. Hair care

A nurse is caring for a patient with a severe infection of the gums. What is one possible nursing diagnosis based on the patient's "at risk" status? A. Risk for self-care deficit B. Risk for altered nutrition C. Risk for infection D. Risk for ineffective tissue perfusion

B. Risk for altered nutrition

A post-surgical patient is requesting hair care from the nurse. The nurse documents the procedure and includes which information? (select all that apply) A. Medications used B. Patient's concerns C. Condition of patient's scalp D. Patient's tolerance of procedure E. Patient's satisfaction

C. Condition of patient's scalp D. Patient's tolerance of procedure E. Patient's satisfaction

The nurse prepares a sitz bath for a new mother. The nurse explains to the patient that a sitz bath is recommended because it __________________. A. Improves skin pH B. Improves pediculosis C. Decreases swelling D. Decreases halitosis

C. Decreases swelling

Which patient would least likely be at risk for skin ulcers? A. A patient who lies in bed most of the time B. One who needs adult briefs changed frequently C. An inactive patient with poor nutrition habits D. One with Alzheimer's disease

D. One with Alzheimer's disease

When assessing a newly admitted patient, the nurse observes a red area on the patient's sacrum. What action should the nurse implement? (select all that apply) A. Rub the red area on the sacrum to increase circulation. B. Apply lotion to the red area on the sacrum to prevent breakdown. C. Apply a bandage to the red area on the sacrum. D. Turn the patient on the right side. E. Assess to see if the red area on the patient's sacrum blanches.

D. Turn the patient on the right side. E. Assess to see if the red area on the patient's sacrum blanches.

A nurse is instructing a newly blind patient how to clean the eyes. What method should the patient use? A. Use plain water and wipe from the outer canthus to the inner canthus. B. Use soapy water and wipe from the inner canthus to the outer canthus. C. Use sterile water and wipe from the outer canthus to the inner canthus. D. Use plain water and wipe from the inner canthus to the outer canthus.

D. Use plain water and wipe from the inner canthus to the outer canthus.

What is the best way to prevent the spread of microorganisms in nursing? A. Educating the staff B. Wearing gloves when going in and out of patient rooms C. Applying lotion after using alcohol-based sanitizers D. Washing the hands before and after each patient

D. Washing the hands before and after each patient

When is it appropriate for family members to be involved in setting hygiene and personal care goals for patients who can communicate their own needs and desires? A. Upon the patient's admission to the nursing unit B. During selection of nursing diagnoses for the patient C. Prior to the patient's discharge from the hospital D. When the patient requires assistance after discharge

D. When the patient requires assistance after discharge

The nurse is caring for a patient with oral cavity sores. Which food item would the nurse advise the patient to avoid? A. Orange slices B. Yogurt C. Apple sauce D. Milk

A. Orange slices

When creating a brochure for parents to help prevent pediculosis, which statement should the nurse include? (select all that apply) A. "Assist your child with checking for head lice regularly." B. "Have the child tell you if his head itches." C. "Look for any patches of hair loss." D. "Leave the child to bathe for 20 minutes every day." E. "Look for bumps near the folds of the skin."

A. "Assist your child with checking for head lice regularly." B. "Have the child tell you if his head itches." C. "Look for any patches of hair loss."

What piece of clothing is best to remove when looking for excoriations? A. Adult diaper B. Headband C. Socks D. Pants

A. Adult diaper

Following collaboration about a patient's hygiene needs, which activities can be delegated to the UAP? (select all that apply) A. Applying lotion after bathing the patient B. Assisting the patient with oral hygiene C. Recording the patient's response to skin care D. Helping a patient shave prior to discharge E. Documenting the patient's self-care abilities

A. Applying lotion after bathing the patient B. Assisting the patient with oral hygiene D. Helping a patient shave prior to discharge

What are possible signs of poor hygiene? (select all that apply) A. Body odors B. Chipped fingernail polish C. Tangled and matted hair D. Excessively long and dirty toenails E. Noticeably warm skin

A. Body odors C. Tangled and matted hair D. Excessively long and dirty toenails

What should the nurse implement regarding the oral cavity and hygiene? (select all that apply) A. Brush the teeth and rinse the mouth with a fluoride, non-drying mouthwash after meals and at bedtime. B. Rinse the mouth with water after meals and at bedtime. C. Brush the teeth each day after breakfast. D. Rinse the mouth with hydrogen peroxide after meals and at bedtime. E. Eat a balanced diet and reduce snacks.

A. Brush the teeth and rinse the mouth with a fluoride, non-drying mouthwash after meals and at bedtime. E. Eat a balanced diet and reduce snacks.

A nurse is initiating a care plan for a newly admitted hospitalized patient who is unable to perform basic ADLs independently. What intervention should be listed in the care plan? A. Daily bed bath and assistance with hygiene, and as needed. B. Patient's family to hire personal caregiver to assist with hygiene needs. C. Educate family about how to perform a bed bath and oral hygiene measures. D. Physical therapy to work on ambulation to the bathroom for toileting.

A. Daily bed bath and assistance with hygiene, and as needed.

Which age-related skin issue increases the risk of pressure ulcers? A. Decreased elastin B. Increased forgetfulness C. Increased aches and pains D. Sun-downers syndrome

A. Decreased elastin

The nurse notices that a patient with a complicated health history has halitosis when the patient speaks. The nurse knows that the patient's halitosis could be caused by ________________? (select all that apply) A. Diabetes B. Poor oral hygiene C. Infections of the oral cavity D. Medications D. Pediculosis

A. Diabetes B. Poor oral hygiene C. Infections of the oral cavity D. Medications

What are the three parts of the nursing diagnosis? (select all that apply) A. Diagnostic label B. Related factors C. Defining characteristics D. Diagnostic statement E. Evidence statement

A. Diagnostic label B. Related factors E. Evidence statement

When caring for a malnourished patient, the nurse performs her skin assessment. Which areas of the skin should the nurse especially observe for redness and breakdown? (select all that apply) A. Elbows B. Sacrum C. Hips D. Heels E. Shoulders

A. Elbows B. Sacrum C. Hips D. Heels

Why is nail hygiene so important? A. Helps prevent the spread of infection. B. Avoids the biting and the chewing of nails. C. Prevents biting on cuticles and hangnails. D. Prevents cutting the skin on hangnails.

A. Helps prevent the spread of infection.

The nurse is preparing to assist a patient with limited mobility with a chair shower. The nurse knows that an increase in pH can cause what changes to the skin barrier? (select all that apply) A. Increase in colonization of pathogenic organisms B. Healing of both superficial and deep wounds C. Damage and irritation to the skin barrier D. Increase in relaxation of the patient

A. Increase in colonization of pathogenic organisms C. Damage and irritation to the skin barrier

Which hygiene and personal care nursing diagnosis is correctly stated? A. Ineffective Health Maintenance related to impaired ability to understand due to brain injury, as evidenced by poor hygiene and unkempt appearance. B. Readiness for Discharge related to eagerness to return home as evidenced by increased independence at hospital. C. Readiness for Enhanced Care related to ability to bathe without assistance. D. Body Image Deficit as evidenced by strong body odors and decayed teeth.

A. Ineffective Health Maintenance related to impaired ability to understand due to brain injury, as evidenced by poor hygiene and unkempt appearance.

Which interventions might the nurse implement in order to prevent pressure ulcers? (select all that apply) A. Keeping the patient's skin clean and dry B. Turning the patient every hour, on the hour C. Resting the patient's calves on pillows D. Ordering a very firm mattress E. Maintaining a low protein diet

A. Keeping the patient's skin clean and dry C. Resting the patient's calves on pillows

A nursing diagnosis of Altered Oral Mucous Membranes related to dental disease will yield which findings upon inspection? (select all that apply) A. Missing teeth B. Halitosis C. Sores on the lips D. Dry mouth E. Sinus drainage

A. Missing teeth B. Halitosis D. Dry mouth

A surgical patient is ordered NPO status. The patient requests to have the teeth brushed. The nurse should brush the patient's teeth using a _________. A. Moistened toothette B. Large-handled tooth brush C. Toothbrush with large amount of toothpaste D. Mouthwash swish with fluoride

A. Moistened toothette

When reviewing a patient's chart, the nurse notes the documentation of a pressure ulcer. What would the nurse expect to find upon assessment? A. Open wound over the sacrum B. Red scaly lesion on buttocks C. Purplish discoloration under the cheek D. An infected surgical wound

A. Open wound over the sacrum

What is included as part of hygienic practices? (select all that apply) A. Oral care B. Shaving C. Exercise D. Foot care E. Nutrition

A. Oral care B. Shaving D. Foot care

The nurse is assessing the oral cavity. The nurse observes that the patient's mucous membranes are very dry. Which of these should the nurse implement? (select all that apply) A. Provide mouth care every two hours and prn. B. Provide the patient with liquids to drink. C. Provide the patient with a snack. D. Provide toothpaste to the patient. E. Provide a non-alcohol mouth rinse to the patient.

A. Provide mouth care every two hours and prn. B. Provide the patient with liquids to drink. E. Provide a non-alcohol mouth rinse to the patient.

A patient arrives to urgent care with an excoriation on the torso. How would the nurse note the results of the wound assessment? A. Red and scaly lesions B. Skin is pink and edematous C. White color noted on the skin D. Bluish discoloration

A. Red and scaly lesions

Which physical trait might a nurse find when treating a patient with gingivitis? (select all that apply) A. Red, swollen gums B. Yellow teeth C. Bad breath D. Cracked teeth E. White tongue

A. Red, swollen gums B. Yellow teeth C. Bad breath D. Cracked teeth

After providing perineal care, the nurse documents any __________________ in the patient's perineal area. (select all that apply) A. Redness B. Drainage C. Odor D. Edema E. Blanching

A. Redness B. Drainage C. Odor D. Edema

An immobile patient is running a fever. The nurse suspects the patient has a decubitus ulcer. The nurse observes the patient's skin for signs of infection, which may include what symptoms? (select all that apply) A. Redness B. Freckles C. Scars D. Swelling E. Drainage

A. Redness D. Swelling E. Drainage

In relation to hygiene, why is it a good practice to clean a patient's mouth? (select all that apply) A. Reduces bacteria after eating B. Protects the teeth C. Reduces bacteria after sleeping D. Cleans the mucous membranes E. Assesses the patient's eating abilities

A. Reduces bacteria after eating B. Protects the teeth C. Reduces bacteria after sleeping D. Cleans the mucous membranes

Which patient characteristics are improved through the provision of personal hygiene care by the nurse? (select all that apply) A. Self-esteem B. Confidence C. Self-image D. Perception E. Beliefs

A. Self-esteem B. Confidence C. Self-image

When discharging a patient with diabetes mellitus, it is important to include which items to buy when educating about the importance of skin integrity? A. Small mirror B. Cuticle clipper C. Open toed shoes D. Slip resistant socks

A. Small mirror

A patient complains of chronic bad breath. What is the best advice to help the patient? A. Stop smoking B. Change to a vegan diet C. Change the patient's brand of floss D. Chew on straws

A. Stop smoking

The nurse is caring for a patient diagnosed with diabetes who has recently undergone an above-the-knee amputation (AKA). When assessing this patient's ability to perform self-care, the nurse should use what type of information? (select all that apply) A. Subjective data B. Objective data C. Patient's answers D. Documentation E. Braden scores

A. Subjective data B. Objective data C. Patient's answers

Why is it important for the nurse to participate in providing a patient's personal care? (select all that apply) A. To spend time with the patient B. To perform a more comprehensive assessment C. To assist the nurse assistant D. To help gain the trust of the patient

A. To spend time with the patient B. To perform a more comprehensive assessment D. To help gain the trust of the patient

A patient arrives to the emergency room with a laceration. What intervention best shows that the nurse is using proper hygiene to prevent infection? (select all that apply) A. Washing hands with soap and water prior to treatment B. Using gloves C. Using sterile pads while trying to control the bleeding D. Using tap water to help wash out the wound E. Having the patient wash hands

A. Washing hands with soap and water prior to treatment B. Using gloves C. Using sterile pads while trying to control the bleeding

The nurse is watching nursing students as they perform a chair bath. What activity, if observed by the nurse, should be corrected? A. Washing the skin and hair before performing the assessment of patient's skin, hair, and nails. B. Undressing the patient and performing a skin assessment before beginning the bath. C. Documenting the patient's Braden score in the electronic health record. D. Palpating the skin during the bath and noting the color, texture, and temperature in the patient's medical record.

A. Washing the skin and hair before performing the assessment of patient's skin, hair, and nails.

Which questions will the nurse ask when formulating a measurable hygiene and personal care goal? (select all that apply) A. Who? B. What? C. Why? D. When? E. Which?

A. Who? B. What? D. When?

What should the nurse do when a patient requests the same gender caregiver for hygiene and personal care, due to cultural preferences? A. Request the family to provide care B. Collaborate with social services C. Accommodate the patient's wishes D. Assess the patient's hygiene needs

C. Accommodate the patient's wishes

An older adult patient with arthritis has difficulty using his hands to button clothing, holding an eating utensil or toothbrush, and turning a door lock. In regards to this patient's discharge from the hospital to home, it is the nurse's responsibility to: A. Notify the healthcare provider. B. Overlook the deficit. C. Assist the patient with community referrals. D. Tell the family to place the patient in a nursing home.

C. Assist the patient with community referrals.

A patient has a surgical wound with staples. The provider has given an order for the patient to shower with the incision covered, but the patient has refused twice. How can the nurse advise the patient? A. There is no need to bathe. B. Bathing has only a small chance of causing infection. C. Bathing cleanses microorganisms from the skin and lessens the chance of infection. D. Assume that the patient knows about infection prevention.

C. Bathing cleanses microorganisms from the skin and lessens the chance of infection.

The nurse is assisting an older adult patient with a history of unsteadiness, who walks with a cane. Which bath is appropriate for this patient? A. Complete bed bath B. Partial bed bath C. Chair shower D. Sink bath

C. Chair shower

What priority nursing action must the nurse perform before a patient receives a shower? A. Ensure the patient would like to take a shower. B. Make sure a shower chair is available. C. Check the provider's orders to determine if showering is safe. D. Determine if the patient will take a standup shower or use a shower chair.

C. Check the provider's orders to determine if showering is safe.

Which outcome is desirable for a pediatric patient being treated for head lice? A. Child's hair will be cleansed with medicated shampoo daily. B. Bed linens will be washed in hot soapy water once weekly. C. Child refrains from sharing personal items with school classmates. D. Mother will find no evidence of lice in child's hair within one week.

C. Child refrains from sharing personal items with school classmates.

The nurse is asking a patient hospitalized with acute pancreatitis questions about the patient's self-care capabilities. Which are examples of questions that the nurse may ask to assess the patient's ADLs? (select all that apply) A. Do you know where you are? B. How many visitors did you have last week? C. Do you always make it to the bathroom on time? D. How often do you take a bath or shower? E. Can you bathe yourself without help?

C. Do you always make it to the bathroom on time? D. How often do you take a bath or shower? E. Can you bathe yourself without help?

A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing diagnosis will the nurse select? A. Dressing Self-care Deficit B. Disturbed Body Image C. Hygiene Self-Care Deficit D. Readiness for Enhanced Self-care

C. Hygiene Self-Care Deficit

A nurse is explaining to a patient the importance of hygienic practices. Why is good hygienic practice important? A. Increases a patient's dependence B. Increases the possibility of infection C. Keeps patients clean, and odor- and infection-free D. Lets the patient take care of hygiene individually

C. Keeps patients clean, and odor- and infection-free

A nurse is developing a care plan for a chronically bedridden patient with a nursing diagnosis of Toileting Self-Care Deficit who is being discharged. Which goal is appropriate for this patient? A. Ambulate to the bathroom independently. B. Ambulate to the bathroom with assistance. C. Locate appropriate homecare assistance. D. Educate family on importance of hygiene.

C. Locate appropriate homecare assistance.

A nurse is reviewing the steps of performing a personal care assessment on a patient requiring bathing assistance. Which step should the nurse perform first? A. Observation of skin, noting dry skin, rashes, sores, and body odor. B. Observation of the fingernails and toenails for color, deformities, cracking, and thickness. C. Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice. D. Continued observation and palpation of the skin and assessment of the patient's peripheral vascular status.

C. Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice.

Why is it important to set measurable hygiene and personal care goals for patients? A. Communicates personal care plans clearly among healthcare team members. B. Encourages patients to participate in self-care planning. C. Provides a means for measuring patient self-care progress. D. Facilitates improved collaboration among multiple healthcare members.

C. Provides a means for measuring patient self-care progress.

A nurse is assisting a patient with teeth-brushing. The nurse notices the patient has difficulty grasping and maneuvering the toothbrush. What can the nurse do to further assist this patient? A. Call for the nursing assistant to help with oral care. B. Have the patient sit while the nurse completes oral care. C. Request for a large-handled toothbrush. D. Have the patient continue brushing without assistance.

C. Request for a large-handled toothbrush.

The nurse is caring for an older adult patient with very fragile skin. The patient has plastic tape on the skin around the IV site. What is the best way to remove the tape without damaging the patient's skin? A. Take the tape corners and quickly pull the tape off the patient's arm. B. Take alcohol and put over the tape and quickly pull the tape off of the patient's arm. C. Slowly pull the tape off while pushing the skin away from the tape. D. Slowly pull the tape off while distracting the patient with the television.

C. Slowly pull the tape off while pushing the skin away from the tape.

The nurse notices an older adult patient has food debris in his teeth. When the nurse mentions it, the patient states, "I clean my teeth every day." What should the nurse assess next? A. Toothpaste B. Toothbrush C. Technique D. Perception

C. Technique

Based on the answers given during an initial health history, the nurse suspects that the patient has a fungal infection in his toenails. What physical exam findings would confirm this suspicion? A. Presence of pediculosis B. Red and swollen nail beds C. Thickening of the nail D. Missing toenails

C. Thickening of the nail

A patient is admitted with pneumonia, but does not allow the nurse to complete a skin assessment upon admission. What is the best way for the nurse to assess the patient's skin? (select all that apply) A. When assisting the patient to the chair B. When the patient is in the bathroom C. When bathing the patient D. When assisting the patient with a shower E. When helping the patient to the bedside commode

C. When bathing the patient D. When assisting the patient with a shower

A patient diagnosed with peripheral neuropathy and related circulatory impairment requires a nail-clipping. The nurse should avoid _______________ when clipping the nails of this patient. A. increased circulation to the area prior to clipping B. use of the patient's own nail trimmer C. nicks and cuts in the skin D. massage of each digit prior to clipping

C. nicks and cuts in the skin

Which statement, if made by the patient regarding oral hygiene, would indicate the need for further education? A. "Flossing every day is important." B. "I should avoid hard candy." C. "Brushing after every meal is vital." D. "Changing my toothbrush every year is important."

D. "Changing my toothbrush every year is important."

Which statement, if made by a chemotherapy patient, indicates the need for further education? A. "I will wear sun block when I go outside for long periods of time." B. "I will check my head for any suspicious wounds." C. "I will wear a hat and sunglasses in the sun." D. "I will scrub with hard brushes when I wash my head."

D. "I will scrub with hard brushes when I wash my head."

Which patient is most at risk for skin ulcers? A. An older female B. A physical education teacher C. An adolescent D. A frail paraplegic

D. A frail paraplegic

A nurse is caring for an older adult woman with advanced dementia who is incapable of self-care. However, the patient insists on brushing her own teeth at bedtime this evening. How should the nurse proceed? A. Allow her to brush her own teeth independently. B. Allow her family to brush her teeth for her. C. Get another nurse to brush the patient's teeth. D. Allow her to brush her teeth with supervision.

D. Allow her to brush her teeth with supervision.

The nurse is assessing a teenager's oral cavity as part of the admission assessment. Which finding, if observed during the assessment, should the nurse refer the patient to the dentist for further care? A. Dry mouth B. Halitosis C. Cyanotic gums D. Broken teeth

D. Broken teeth

Which assessment data would indicate a potential complication associated with the skin of a patient? A. Wrinkling B. Age spots C. Expression lines D. Crusting

D. Crusting