VNSG 1323: Chapter 17 Prep U Questions

A nurse is providing oral care for a client who has been in a coma for 2 weeks. For what oral hygiene alteration might this client be at risk?

White patches may be present that indicate a fungal infection called thrush Explanation: White patches in the oral mucosa indicate thrush. Decreased or absent gag reflex increases the risk for aspiration; however, not all clients in a coma are affected. Alterations in cognitive function and/or consciousness increase the risk for alterations in oral tissue and structure integrity. A client who is receiving chemotherapy is at high risk for bleeding gums, which is unrelated to a client who is in a coma.

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. Which statement by the nurse should be made first?

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks." Explanation: The client needs education about why bathing is important. Knowledge deficit, and fear of loss of independence and/or privacy, may be impacting the client's choice. The nurse will first provide information about the reason that bathing is important, and then assure the client that privacy will be maintained, empowerment will be given, and autonomy will be respected.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair." Explanation: Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.

A parent reports that their home water is not fluoridated and questions the nurse whether it would be benefitial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?

"In the absence of fluoridated water supplies, supplementation is often recommended." Explanation: Supplements of fluoride until the age of 14 may be recommended if the local water system is not fluoridated. Brushing teeth with a fluoride toothpaste twice daily, and additional fluoride measures for those at high risk, are recommended to reduce risk of dental caries in all age groups.

The acute care nurse is talking with an older client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact." Explanation:Nurses should examine bathing practices and consider the effect on the client's skin. This statement is most appropriate "That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact." The response about reporting the person is not warranted. Offering the client to be bathed again is therapeutic but not professional as it undermines the nurse who chose not to "scrub" the client. Offering the client to bathe themselves is appropriate but not professional as the nurse is promising the client their favorite soap when they feel better which may not occur.

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." Explanation: Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratosis, as these spots are raised in appearance. The spots are not likely cancer and do not need to be removed.

A nurse is assisting a client to shave his beard. Which statement accurately describes a recommended step in this process?

Apply cream to area to be shaved in a layer about ½-inch thick. Explanation: Steps for the shaving procedure include: Cover client'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 ½-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 client is unable tto remove their contact lenses after being involved in a motor vehicle crash. What nursing actions can be used to remove the client's soft contact lenses? (Select all that apply.)

Ask the client remove them, if able. Use the pads of the index finger and thumb to gentle pinch and remove the lens. Use a commercially available tool with a small suction cup. Explanation:A client with contact lenses is taught how to properly remove them. Using the pads of the index finger and thumb and a gentle pinch is the most common way to remove the lens. A commercially available tool with a small suction cup is often used with rigid gas permeable contact lens. Gentle pressure should never be used. The cotton-tipped applicators are not useful to remove contact lenses.

A nurse needs to clean and bathe a client who has undergone surgery following a motor vehicle accident. What type of bath will negate the need to rinse the client?

Bag bath Explanation: Rinsing is not required during a bag bath. During a shower, tub bath or bed bath, the nurse must remove soap residue in order to prevent skin irritation.

A nurse is teaching self-care measures to a client diagnosed with scabies. Which instruction is accurate? (Select all that apply.)

Bathe thoroughly in the morning and at night. Apply prescribed medication after bathing. Don clean clothes after bathing. Avoid skin-to-skin contact with uninfected people. Explanation: Scabies is an infestation with an itch mite that burrows within the webs and sides of fingers, around arms, axilla, waist, breast, lower buttocks, and genitalia. The client should bathe thoroughly in the morning and at night, apply prescribed medication after bathing, don clean clothes after bathing, and avoid skin-to-skin contact with uninfected people. Treatment of scabies ends when the infestation is eliminated, so the medical regimen is not lifelong.

Which is a recommended guideline when removing contact lenses from a client's eyes?

Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea. Explanation: Gentle pressure should be used to center hard or gas-permeable lenses on the cornea. Once removed, lenses should be placed in the appropriate container, identifying the right and left lens. If an eye injury is present, the lenses should not be removed because of the danger of causing an additional injury. If the lenses cannot be removed, they should be removed with the appropriate tool designated for the type of lenses in place.

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?

Cleanse to remove secretions from less-soiled to more-soiled areas. Explanation: To ensure proper perineal care, the nurse should cleanse to remove secretions and excretions from least contaminated area to the most contaminated area. The nurse must also prevent direct contact with 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.

A nurse is assessing the skin of an older client with dry skin and notices several areas of scratches and abrasion. Interventions should be implemented to:

Decrease the risk of infection. Explanation: The skin protects the body. Invasion of the body by bacteria is prevented by intact skin. Injury to underlying tissues and organs is also decreased by intact skin.

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 Explanation: To promote autonomy, encourage the client to participate in care in such a way that dignity is preserved, and energy is conserved. Asking the client to participate in washing own face and hands is appropriate. Other interventions are inappropriate.

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:

Facilitates oil distribution Explanation: 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.

Bathing should be performed in an orderly, head-to-toe manner.

False

According to common practice, when are the bed linens usually changed?

Following the bath Explanation: Usually, bed linens are changed after the bath. A client may need a bath in the bed therefore after the bath the linens are changed. Some agencies change linens only when soiled. The linens are not changed before bed or following receiving visitors.

An elderly client has worn an artificial eye since advanced glaucoma necessitated enucleation (removal of the eye). What action should the nurse perform immediately before assisting the client with resinsertion of the artificial eye?

Gently rinse the client's eye socket with clean water or normal saline. Explanation: The nurse irrigates the eye socket with water or saline before reinserting the artificial eye. Antibiotic ointments and petroleum jelly are not applied to the artificial eye and lubricants are not applied to the client's eye socket.

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?

Partial Care Explanation: 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.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include?`

R/t right-sided weakness Explanation: Self-care deficit: Bathing is related to lack of motor skills, coordination, mental status, and endurance when performing bathing activities. Right-sided weakness is an appropriate statement about why this problem exists. A person's inability to perform bathing independently is more of a sign or symptom in the "as evidenced by (AEB)" statement of a nursing diagnosis. Related to impaired mobility is a nursing diagnosis and cannot be used as a "related/to" statement.

A nurse is preparing to give a client a towel bath. Place the steps of this skill in the correct sequence from first to last.

Prefold and moisten the towel or bath sheet with approximately one-half gallon (2 L) of water heated to 105° to 110° F (40° to 43° C) and 1 oz (30 mL) of no-rinse liquid cleanser. Unfold the towel so that it covers the client. Use a separate section to wipe each part of the body, beginning at the feet and moving upward. Fold soiled areas of the towel to the inside as you bathe each area and allow the skin to air-dry for 2 to 3 seconds. Position the client on the side and repeat the procedure. Bathe the client's back, and then repeat the procedure Explanation: The nurse prefolds and moistens the towel or bath sheet with approximately one-half gallon (2 L) of water heated to 105° to 110°F (40° to 43°C) and 1 oz (30 mL) of no-rinse liquid cleanser. The nurse unfolds the towel so that it covers the client and uses a separate section to wipe each part of the body, beginning at the feet and moving upward. The nurse folds the soiled areas of the towel to the inside as the nurse bathes each area and allows the skin to air-dry for 2 to 3 seconds. After washing the front side of the body, the nurse positions the client on the side and repeats the procedure. The nurse unfolds the towel so that the clean surface covers the client. The nurse bathes the client's back, and then the buttocks. When the towel bath is complete, the nurse changes the bed linens.

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. Explanation: When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the client to overcome dryness of the lips caused by oxygen therapy. The client's position should be changed every 2 hours to promote comfort and circulation for the skin primarily.

A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do?

Provide supplies and assist with hard-to-reach areas. Explanation: 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. The nurse would provide supplies and orient client to the bathroom in self care. Providing complete care or personal hygiene requires: bathing, showering and washing, foot, hair, nail, perineal, shaving, mouth and oral, and denture care.

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

Pulling the razor against the direction of hair growth Explanation: When shaving a client, it is appropriate to wash the skin prior to shaving and to rinse the razor after each stroke. It is also appropriate to apply direct pressure if the skin is nicked from the razor. It is not appropriate to shave against the direction of hair growth. Shaving with the direction of the hair reduces the potential for irritation of the skin.

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 technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. Explanation: Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. Failing to pull the foreskin back into place may cause tissue damage to the penis. The foreskin can be retracted and cleaned. Waiting 10-15 minutes can cause damage to the penis. It is not necessary to soak the penis in warm water before cleaning the shaft.

A home care nurse visits a client for follow up. During the visit, the client asks the nurse to explain the process for cleaning the soft contact lenses that he recently acquired. Which instruction would the nurse include when educating the client about contact lens care?

Rinse with cleaning solution to remove debris. Explanation: To care for soft lenses, a cleaning solution is used to loosen and remove film and debris. After cleaning, rinsing with a rinsing and disinfecting solution is necessary to remove loosened deposits. Then the lenses are covered with rinsing solution for storage. Before insertion, each lens is rinsed again with the rinsing solution to ensure removal of particulate matter. Recommended care may include a weekly heat or chemical lens cleaning to remove accumulated protein, lipids, and mucin. Eyeglasses are washed under warm water and dried with facial tissue or a lens cloth. Artificial eyes are stored in saline or water containers.

The nurse is caring for a client with tinea cruris. What assessment findings does the nurse anticipate finding?

Sore, itchy cluster of scaly, cracked vesicles Explanation: Tinea cruris is a fungal infection of the groin and surrounding area. This condition appears as a ring or cluster of papules or vesicles that cause itching, and may be scaly, cracked, and sore. Other findings reflect other conditions, not tinea cruris.

A 76-year-old client is admitted to the health agency with a stroke. The nurse, while bathing the client, starts wiping and cleaning the body from feet onward. The client is incapable of assisting the nurse in the bathing process. Which technique is the nurse using to bathe the client?

Towel Bath Explanation: The nurse is using the towel bath technique to clean and bathe the client. Because the client cannot do anything on their own and cannot assist the nurse, the nurse uses a large towel to cover and wash the client. The nurse is not giving a bed bath, partial bath, or tub bath to the client because during a bed bath, the nurse bathes the client with a basin of water at the bedside and the client may actively assist with some aspects of bathing. A partial bath means washing only those body areas subject to greatest soiling or that are sources of body odor, generally the face, hands, axillae, and perineal area. Partial bathing is done at a sink or with a basin at the bedside. If the client can work independently, the nurse will suggest the client to have a tub bath.

A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. What technique would the nurse employ when providing foot care?

Use an antifungal powder on the client's feet, if necessary. Explanation: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.

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. Explanation: Bath oils can be added to a basin when administering a bed bath. However, they should never be used in the tub or shower, as they increase the risk of falls. All other options are correct.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Use electric razor for shaving purposes. Explanation: Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, in place of a safety razor, and a soft bristle toothbrush will reduce bleeding during care of skin and gums. The client should not be advised to take aspirin, buy a hard-bristle toothbrush, or explain that prolonged bleeding is normal.

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. What would the nurse expect to find in the client?

inflamed bites along the hairline Explanation: 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.