Fundamentals of Care: Hygiene/Sleep & Rest

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse?

✅"Can you tell me more about your feelings?" 📑Rationale: Clients who are possibly depressed may refuse to participate in prescribed treatments including recreational therapy. A neutral statement that focuses on the client is the best response to the client. This statement offers an opportunity for the client to detail concerns, and there is no judgment on the part of the nurse. Option 2 encourages the client to verbalize but is judgmental. Option 3 cuts off the communication with falling back on prescribed activities. Option 4 involves giving advice and cuts off communication.

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

✅Provide a soft toothbrush. ✅Check oral mucous membranes. ✅Check for missing teeth and cavities. 📑Rationale: The nurse should assess oral mucous membranes for sores caused by chemotherapy. A soft toothbrush should be provided to prevent irritation of the mucous membranes. Assessment of the client's dentition helps identify any limitations in diet. The nurse should use clean gloves while helping with oral hygiene. Abrasive toothpaste or alcohol-based mouthwash may cause irritation of the client's mucous membranes and bleeding.

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first?

✅A client who was admitted 2 days ago with a pelvic fracture 📑Rationale: The UAP should help the client who has a pelvic fracture first because this client has the most limitations with toileting. The nurse may consider the other clients be helped in this order. The client with left foot amputation may be able to transfer independently to a bedside commode. The client with early dementia requires only a reminder to use the bathroom. The last client is independent with toileting because she is ambulatory.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider?

✅Valerian. 📑Rationale: Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness. Garlic is used as an antioxidant and to lower cholesterol levels. Lavender is used as an antiseptic and fragrance for a mild sedative effect. Glucosamine is an amino acid that assists with the synthesis of cartilage.

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

✅"I drink hot chocolate before bedtime." ✅"I plan out my goals for work for the next day" 📑Rationale: Sleep problems usually involve either getting to sleep or staying asleep. Hot chocolate contains caffeine and may interfere with going to sleep. The client should not over plan for the next day because this will lead to stressful concerns and stimulation of the nervous system. Many nonpharmacological sleep aids can be used to influence sleep. The client should avoid caffeinated beverages and stimulants (e.g., tea, cola, chocolate) and foods that contain tyrosine (e.g., cheddar cheese). The client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. Smoking and alcohol should be avoided. The client should avoid large meals, peanuts, beans, fruit and raw vegetables that produce gas, and snacks that are high in fat and difficult to digest.

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Based on the client needs, the nurse instructs the UAP to bathe which client first?

✅A confused client who is incontinent of stool and urine. 📑Rationale: The confused client should be bathed first because bowel/bladder incontinence would lead to skin breakdown. The nurse may consider the order of the other clients based on their conditions. The client who has multiple traumas is at risk for developing skin breakdown and wound infection. The client who was admitted for dehydration and failure to thrive requires assistance with hygiene needs. The client who is independent with activities of daily living (ADLs) does not require assistance with hygiene, but should still be monitored for any needs.

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

✅A glass of warm milk ✅A cube of Swiss cheese ✅A cup of caffeine-free tea 📑Rationale: Milk and milk products contain the essential amino acid tryptophan, which enhances sleep by promoting the production of the neurotransmitter serotonin in the brain. Drinking a glass of warm milk or eating a cube of Swiss cheese may be helpful to sleep. Caffeine-free tea may be soothing and will not keep the client awake. The client should avoid spicy foods such as a taco before bedtime. The client should also avoid alcohol such as wine at bedtime. The client may become sleepy but often wakes up in a few hours. Caffeine products including chocolate and coffee should not be taken at bedtime.

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure? Select all that apply.

✅Cleanse each eye moving from the inner canthus to the outer canthus. ✅Use a clean wet cotton ball or different area of a clean wash cloth for each eye. 📑Rationale: The nurse cleanses the eye by wiping from the inner canthus to the outer canthus using a clean wet cotton ball or different area of a clean wash cloth. This provides for best asepsis because it moves from a cleaner area to a dirtier one. There are no cleansing solutions that are applied inside the eye in the conjunctival sac. Any soap will be irritating to the eye so only water is used to provide eye care.

The nurse is discussing the care needs with an unlicensed assistive personnel (UAP) who is preparing to bathe a client who has mild dementia and requires minimal help with hygiene. The nurse identifies which client need as the highest priority when giving the instructions?

✅Maintain client safety. 📑Rationale: When planning care for a client with dementia, safety is a priority because the client may not have the insight to maintain a safe environment independently. Respecting client privacy, promoting social interaction, and developing a therapeutic relationship are also important but less so than safety.

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.

✅A soft toothbrush ✅Irrigation syringe ✅Bite stick or a padded tongue blade ✅Suction with oral suction catheter attached 📑Rationale: Mouth care is important for the unconscious client. A soft toothbrush and mouthwash such as half strength mouthwash with water or hydrogen peroxide are needed to perform oral care. A bite stick or padded tongue blade is used carefully to open the mouth; the nurse should not use gloved fingers to open the mouth to prevent injury to self. Small volumes of fluid are injected gently through an irrigation syringe used in cleaning the mouth, and oral suctioning is used to prevent aspiration. The client should be placed on the side to allow the fluid to drain and prevent aspiration. Full strength hydrogen peroxide is not used as mouth wash because of excessive harshness and foaming.

A client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions should the nurse offer the client to help reduce the pain? Select all that apply.

✅Distraction ✅Back massage ✅Relaxation breathing 📑Rationale: Non-pharmacological interventions that the nurse can use for the client are those that do not involve prescribed medications or procedures. Distraction involves teaching the client to concentrate on some other subject besides pain and may include reading or watching television. Back massage is a back rub given to relieve muscle tension and helps the client relax. Relaxation breathing is an intentional controlled deep breathing technique that also helps the client relax. A placebo is a substance or procedure given to a client as an effective treatment that has no known beneficial effect. The client is told the placebo will improve symptoms and is no longer prescribed by primary health care providers (PHCPs). Acupuncture is a complementary therapy that involves placing needles in specific areas of the body along meridians (lines) to relieve pain and is not a nursing intervention. TENS is an electrical current stimulator applied to an area of pain; it is not a nursing intervention. TENS are prescribed by PHCPs and physical therapists and are available over the counter.

The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions should the nurse consider performing before assisting the client to go to the recreational therapy session? Select all that apply.

✅Make sure the client is wearing a clean undergarment. ✅Encourage the client to use the restroom just before the activity. 📑Rationale: Older clients may find new activities stressful and become stressed over physiological problems such as incontinence. The nurse works with the client to make the new activity a positive experience even if the client has incontinence. The nurse plans to avoid the client becoming incontinent by promoting elimination just before the activity and assisting with hygiene (clean undergarment). Holding fluids for 4 hours before the activity is excessive and may harm the client. Telling the client that others also have problems belittles the client's concerns. Delaying a diuretic for an hour may be a reasonable adjustment to avoid incontinence for the client during recreational therapy. Basic physiological needs are a priority in administering nursing care. The priority would be to keep the client clean and dry and to avoid embarrassment.