Chap 31 hygiene

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

51-year old with hemorrhoids Explanation: A sitz bath includes the immersion of the buttocks and perineum in a small basic of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. The other clients do not get as much benefit from this type of bath.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:

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

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. Explanation: Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care.

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

"I use cotton-tipped applicators daily to remove cerumen." Explanation: Healthy ears require little to no care. Cerumen (ear wax) can accumulate, causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicators because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

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

"I will set up your bath for you. I will come back and help you with your bath." Explanation: The nurse must value and support the client becoming independent in care.

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 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." Explanation: Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visiting the dentist every 6 months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damage the hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansing the skin regularly using lotions and creams while ensuring good cleansing of the axilla and application of deodorant and antiperspirants; and cleaning the perineal areas. Hygiene also promotes a sense of well-being and positive self-image.

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." 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 keratoses and this doesn't address the client's concern of brown patches on their face and arms.

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 statement from the students indicates 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." Explanation: The hospital can be a stressful environment for clients. It is important to provide an environment of comfort and ensure the client has everything he or she needs while in the hospital. Asking the client if he or she needs anything before leaving the room demonstrates caring and increases safety by decreasing the risk of falls when client gets out of bed independently. Ensure good ventilation and clean room environments by removing unpleasant odors and using room deodorizers that are not offensive. Keep the room comfortable for the client. Avoid behaviors that will limit sleep or cause concern to the client, such as loud noises, interrupting the client several times daily for procedures, and discussing information outside a client's room.

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. Explanation: There are several factors that affect one's ability to perform self-care. These are factors that nurses must take into consideration when planning and delegating care of clients. Clients should have stable vital signs, be pain free, and have a desire to perform self-care. It is also important to prioritize client needs throughout the day. A client being discharged requiring partial care would be the priority client.

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. Explanation: Adolescents have enlarged sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining to the mucous membranes. Secretions from skin glands occur later than age 3 months. While the skin may have more wrinkles as a person ages, the skin actually becomes thinner with age.

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 non-skid floor. Explanation: The nurse can ensure the client's safety by checking for non-skid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs as they increase the risk of falls.

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. Explanation: Bathing/hygiene self-care deficits resulting from hospitalizations and complications require return of strength and motor abilities. An appropriate goal is for the client to actively and independently participate in hygiene and self-care. In order for the nurse to document that the outcome was met, the nurse must see the client perform the activity.

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. Explanation: Clients who have diabetes, impaired circulation, or thick nails are at risk for vascular complications secondary to trauma. The services of a podiatrist should be obtained. It is not appropriate to clip the toenails with large clippers, use a handheld electric rotary file, or clean under the toenails with a wooden orange stick.

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. Explanation: When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Peritoneal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

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.

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

Heat the entire package in the microwave, following the manufacturer's recommendation. Explanation: One self-contained bathing system consists of a package containing 8 to 10 premoistened, disposable washcloths. The unopened package is warmed in the microwave or stored in a warmer until use. Each part of the client's body is cleansed with a fresh cloth. No rinsing is required. The skin is allowed to air dry (for about 30 seconds) so that the emollient ingredient of the cleaner remains on the skin.

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 Explanation: Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowing the client to shower independently would be appropriate. The client is not unstable enough to prohibit hygiene measures.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily. Explanation: Keeping hair off the face and washing the hair daily will help prevent oil from transferring from the hair to the skin, causing clogged pores. The client should avoid squeezing or picking infected areas because this can spread the infection and cause scarring. The adolescent should be taught to gently wash the face twice a day with a mild cleanser and warm (not hot) water.

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. Explanation: Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.

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 solution should the nurse use for the storage of the client's lenses after removal?

Normal saline Explanation: Contact lenses are most commonly stored in normal saline. Sterile water contains water that is sterilized and packaged for use as an irrigant. A hypertonic solution is a particular type of solution that has a greater concentration of solutes on the outside of a cell when compared with the inside of a cell (e.g., 3% saline). A hypotonic solution is any solution that has a lower osmotic pressure than another solution (e.g., 0.45% saline).

Which health problem is most clearly suggestive of a history of inadequate dental care?

Periodontitis Explanation: Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency. Dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss.

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

Providing a back rub before bed Explanation: A back rub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?

Pull down on the lower lid and exert slight pressure below the lid. Explanation: To remove an artificial eye, pull down on the lower eyelid and exert slight pressure below the eyelid; this will overcome the suction holding the eye in place.

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. Explanation: Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

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. Explanation: The nurse should encourage the client to wear the dentures, if not contraindicated. Dentures enhance appearance, assist with eating, facilitate speech, and maintain the gum line. Denture fit may be altered if dentures are not used for long stretches. The nurse should encourage the client to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. In addition, the nurse should encourage the client to refrain from placing the dentures in the bed clothes because they can be lost in the laundry. The client should store dentures in cold water when not in the mouth. Leaving dentures dry can cause warping, leading to discomfort when worn.

A nurse is explaining the use and handling of dentures to an older adult client. What measures should the nurse mention to the client?

Store the dentures in water in a covered cup. Explanation: The nurse should tell the client to remove and store the dentures in water in a covered cup. The nurse should tell the client to clean the dentures and removable bridges with a toothbrush, toothpaste, and cold or tepid water—not hot water—to prevent damage. The nurse should not tell the client to clean dentures with a tissue or to keep them wrapped in a tissue; the tissue can stick to the dentures, leading to possible contamination and transfer of microorganisms.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration. Explanation: Clients who are not alert are at risk for aspirating liquid into their lungs. Aspirated fluids predispose a client to pneumonia. The nurse should use special precautions to avoid getting fluid into the client's airways and lungs. Position the client on the side with the head slightly lowered. An upright position will not protect the airway from fluids entering. The lithotomy position is used for vaginal and anal exams and will not protect the airway from fluids and aspiration.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate?

Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. Explanation: Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. The IV tubing and IV fluids should not be discontinued, if possible. Leaving the gown in place is inappropriate as the client needs a clean gown after a bath. A nurse should avoid cutting the regular gown if possible.

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.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers. Explanation: Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation. Povidone-iodine, also known as iodopovidone, is an antiseptic used for skin disinfection before and after surgery. It may be used both to disinfect the skin of the client and the hands of the health care provider, but is not used as a bathing agent. The client should be cleaned daily as this will not preserve skin integrity. A complete bath is not necessary each time a client has an episode of incontinence because this can dry out the skin and put the client as risk for an infection by decreasing the skin flora.

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

When dentures are left out for long periods of time the client's gum lines may change, causing the dentures to fit poorly. Dentures should always be kept in a denture cup with cold water to prevent the dentures from drying out and cracking or warping. A soft toothbrush and toothpaste with lukewarm water for rinsing should be used to clean dentures.

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.

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. Explanation: Shampooing removes dirt and oil from the hair and scalp. Clean hair makes clients feel good about their appearance and enhances feelings of self-worth.

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

how often the client is bathing. Explanation: Frequent bathing for the older client can dry skin and contribute to skin breakdown.

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

loss of hair Explanation: The nurse must be alert to factors that are known to cause hair or scalp problems, such as hair loss from treatment with certain chemotherapeutic agents. The chemotherapuetic agents cause cellular death of the rapid cell division of the hair and gastrointestinal system. Most agents do not affect the skin or nails and do not cause excessive 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 Explanation: Pediculosis is an infestation of the hairy parts of the body or clothing with the eggs, larvae or adults of lice. The crawling stages of this insect feed on human blood, which can result in severe itching. When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the client will shampoo the hair once and not follow through with a second washing. Pediculosis requires treatment which is combing out the nits or eggs and is not self-limiting. Pediculosis is not a reflection of inadequate hygiene. It is also not necessary to destroy the child's clothing and bedding.

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. Explanation: Fluoride strengthens teeth during their formation and helps prevent dental caries. Children need both milk and water. There is no reason for alternation between tap and bottled water if the bottled source has adequate flouride.

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 Explanation: A traditional bed bath with linen change provides the greatest opportunity for full cleansing. The client is unable to perform assistance with a shower, and is not a candidate for a bed bath. Although a bag bath may be useful, the traditional bed bath with linen change provides the best opportunity for infection control in observance of the mild skin breakdown that has been noted.

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?

underneath the breasts and in between skin folds Explanation: Skin fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. The antecubital fossa (inner portion of arm) and popliteal space (behind the knee) are not skin fold areas that require cleaning. The eyes, toenails, and fingernails are not sources of odor.