Fundamental Nursing Chapter 30 Hygiene PrepU

For which of the following patients would the use of a flannelette blanket as a bottom sheet be recommended?

An elderly person with arthritis

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is:

"I will set up your bath for you. I will come back and help you with your bath."

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:

understand that his culture may influence his hygiene and ask him his preference

A nurse has finished providing morning care for the client. What safety measures should the nurse employ prior to leaving the client's room? Select all that apply.

• Place the call light near the client within reach. • Test the functioning of the bed and bed controls. • Place the bed in the lowest position. • Ensure the bed is locked.

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.

Which of the following modifications to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. When delegating care to an Unlicensed Assistive Personnel (UAP), the nurse explains that the following are true regarding safety of the older adult while bathing. Select all that apply.

Using a long-handled shower brush or attachment helps with limited mobility. • Water temperature should be monitored carefully due to decreased temperature sensation. • Use of a tub/shower seat may be necessary if balance problems are present.

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further teaching by the nurse?

"I use cotton-tipped applicators daily to remove cerumen."

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."

Which of the following methods can be used to remove a patient's soft contact lenses? Select all that apply

• Ask the patient remove them, if able. • Use the pads of the index finger and thumb to gentle pinch and remove the lens.

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? (Select all that apply.)

• Cheilosis may present as reddened fissures at the angles of the mouth. • Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. • Caries may exist in the teeth, resulting from the failure to remove plaque

What are appropriate nursing measures when caring for a patient's eyes and ears? (Select all that apply.)

• Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cotton ball; or compress. • Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. • Clean the patient's external ear with a washcloth-covered finger.

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

Which nursing actions are recommended guidelines when performing oral care? (Select all that apply.)

• If desired, use salt and sodium bicarbonat e as cleaning agents for short-term use. • Ideally, brush teeth immediately after eating or drinking. • If desired, use an automatic toothbrush to remove debris and plaque from teeth

You are preparing to perform oral care for a patient who has full dentures. Which of the following actions should you take? Select all that apply.

• Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. • Provide privacy while the patient removes dentures from the mouth. • Use a toothbrush and paste and gently brush all surfaces.

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding? Select all that apply.

"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." • "Hygiene measures have no affect on skin." • "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums

For which of the following patients is foot care likely the highest priority?

A patient who is obese and has a diagnosis of type 1 diabetes

A nurse is discussing care of her four clients with an unlicensed assistive personnel (UAP). The UAP is planning morning care and hygiene for the clients. Which client should the nurse instruct the UAP to offer hygiene measures to first?

A pleasantly confused 86-year-old female requiring partial care being discharged today. Correct

When providing oral care, which of the following does the nurse recognize as the most important component of the oral care process?

A thorough mechanical cleaning

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

A nurse caring for the skin of patients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of bathing/hygiene: self-care deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care.

A nurse teaches student nurses recommended skin care practices for their patients. Which of the following statements accurately describes one of these guidelines?

Avoid using soap and water.

A nurse is explaining the need for bathing to an elderly client who has been avoiding her daily bath. Which of the following benefits of bathing should the nurse explain to the client?

Bathing reduces the possibility of infection.

Which of the following 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.

A nurse is preparing to help a client with a skin infection have a tub bath. In which of the following ways can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor.

A nurse is caring for an elderly client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, which of the following should the nurse do?

Clean the dentures over a plastic basin or towel.

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 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

A nurse is preparing the environment in a hospital room for a newly admitted patient. Which actions are recommended? (Select all that apply.)

Do not place soiled dressings or anything with a strong odor in the waste receptacle in the patient's room. • In general, keep the room temperature between 20° and 23°C (68° and 74°F). • Avoid carrying out conversations immediately outside the patient's room

A nurse is making an occupied bed. Which of the following is a recommended guideline for this procedure?

Fan-fold soiled linens as close to patient as possible.

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

Following the bath

Foot care is an essential part of routine hygiene. What is an important nursing consideration when planning foot care for diabetic patients?

Foot care should not include soaking the feet.

A nurse assisting a patient 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. How should the nurse record the findings in the client's medical record?

Gingivitis

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

In order to maintain a healthy and hygienic integumentary system, a nurse is clipping the overgrown nails of an older adult client. Which other part should the nurse check to maintain the hygiene of the client's integumentary system?

Hair

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which of the following methods for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis?

Imbalanced nutrition: less than body requirements

The nurse is teaching an adolescent how to treat acne. What would the nurse include as a teaching point?

Keep hair off the face and wash hair daily.

When caring for a patient with dentures, what should the nurse teach the patient?

Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit.

A school nurse is conducting a teaching session for the parents of elementary students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student?

Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms.

Which of the following statements accurately describes a recommended step when making an unoccupied bed?

Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side.

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What condition may result from chemotherapy?

Loss of hair

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 clients MAR

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the client's lenses after removal?

Normal saline

Which of the following health problems is most clearly suggestive of a history of inadequate dental care?

Periodontitis

A client who has been staying at a health care facility for 2 months develops corns on his feet. A corn is a kind of inflammation on the feet. To which of the following people should the nurse send the client for relief?

Podiatrist

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

A nurse is washing a patient's hair using a shampoo cap. Which of the following is an accurate step in this procedure?

Remove and discard the cap and dry the hair with a towel.

Which nursing action is appropriate when providing foot care for a patient?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

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

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures?

Store the client's dentures in water when the client is not wearing them.

A nurse is explaining the use and handling of dentures to an elderly client. Which of the following measures should the nurse mention to the client?

Store the dentures in water in a covered cup.

The nurse is assisting a 56-year-old female, who has undergone a mastectomy, with her morning care. Which action by the client requires further teaching by the nurse?

The client applies deodorant.

A nurse is caring for a client with a decreased level of consciousness. 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.

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which of the following teaching points should the nurse prioritize when educating the parents of students who have lice and nits?

The importance of completely finishing the prescribed treatment

A nurse is asked to wash the hair of a client who has a spinal cord injury. Which guideline should the nurse follow when performing this procedure?

Use a makeshift protection area consisting of a protective pad and direct the water into the container.

When bathing a patient, the nurse notices that the patient has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching

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 providing perineal care for a female client who has a decreased level of consciousness. Which of the following techniques should the nurse employ when providing this care?

Wipe from the pubic area toward the anal area

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

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:

assessment of tissues.

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

how often the client is bathing.

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation.