Hygiene

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

51-year old with hemorrhoids

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? Select all that apply

"I will rinse with water when I cannot brush." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice."

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction?

"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

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 taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?

"What are your expectations about bathing at this time?

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?

"I am placing the new linens under the rolled, soiled lines to avoid contamination."

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction?

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

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? Select all that apply.

"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."

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."

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:

hair should be washed as often as necessary.

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

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

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

Check that the bathroom has a nonskid floor.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to 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 while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention

Contact a podiatrist to care for toenails.

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 is making an unoccupied bed for a hospitalized client. 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 to form a corner, according to agency policy.

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.

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?

Hold dentures over a plastic basin or towel when cleaning them."

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

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

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

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

A nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

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

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokes.

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

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals

She has motivation to participate in self-care.

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

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

Use a tepid bath to relieve inflammation and itching

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.

Use a tub/shower seat if balance problems are present. Carefully monitor water temperature. Provide the client a long-handled shower brush or attachment if experiencing limited mobility.

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

Use an electric razor for shaving purposes.

In which situation would it be appropriate to shave the beard of an unconscious client without his permission?

When inserting an endotracheal tube

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.

Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition

caries

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should:

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 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.

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

how often the client is bathing.

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

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education 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 pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:

there is a need to determine if the bottled water has fluoride.

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

traditional bed bath with linen change


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