N400, PrepU for Ch 30 (Hygiene)
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? a) "Use your ungloved hands to remove an unconscious client's dentures." b) "Clean dentures with hot water to eliminate bacteria." c) "After brushing dentures, leave them out of the client's mouth overnight." d) "Hold dentures over a plastic basin or towel when cleaning them."
"Hold dentures over a plastic basin or towel when cleaning them." Explanation: Gloves should always be used to remove an unconscious client's dentures. Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth so the gum lines do not begin to change. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.
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? a) "You will need to sit up for your bath, and then I will change your bed." b) "You will be able to take your bath by yourself tomorrow when you can get up." c) "I really have limited time. Let me give you your bath right now." d) "I will set up your bath for you. I will come back and help you with your bath."
"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.
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. a) "Hygiene measures have no affect on skin." b) "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." c) "Bathing regularly and applying lotion and cream as needed are important." d) "It is important to include hair care and shampooing along with brushing in your hygiene routine." e) "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums."
"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 six 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.
The community health nurse has identified that a client has head lice. When educating the client about treatment, what information should the nurse include? a) "Cut your hair as short as you're comfortable with and wash your hair carefully twice a day." b) "Make sure that you follow the shampoo instructions closely and don't exceed the recommended frequency." c) "Have someone monitor your scalp daily for the next week and contact your doctor if the lice don't spontaneously resolve." d) "Discard your pillowcases and any sweaters that you've worn in the last 7 days."
"Make sure that you follow the shampoo instructions closely and don't exceed the recommended frequency." Explanation: OTC pediculicidal shampoo is commonly used. If it is, patients and/or caregivers require instructions on proper use because neurological side effects may be associated with overuse of these shampoos. Lice infestations are not self-limiting and regular shampoo is ineffective. Linens and clothes must be cleaned thoroughly, but they do not normally need to be discarded.
The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse? a) "You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening." b) "It is very uncommon for a child of this age to have bedwetting issues." c) "Did any of your other children have this problem?" d) "While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6."
"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6." Explanation: Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.
The nurse is caring for four clients. For which client is a sitz bath most appropriate? a) 60-year old who is 1-day post-op from a knee replacement b) 73-year old with pneumonia who can get up to bedside commode c) 42-year old recovering from a C-section delivery d) 51-year old with hemorrhoids
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.
A nurse caring for the skin of clients of different age groups should consider which accurately described condition? a) An infant's skin and mucous membranes are protected from infection by a natural immunity. b) An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. c) Secretions from skin glands are at their maximum from age 3 on. d) The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness.
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 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) A comatose 65-year-old man whose vital signs are: T: 98.7, P;60, R:9, B/P: 86/46. b) A pleasantly confused 86-year-old female requiring partial care being discharged today. c) A client with body odor refusing to bathe. d) A 20-year-old man who is able to independently perform self-care and is recently medicated for pain.
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.
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? a) Assess the skin every day using the Braden scale. b) Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). c) Assign a care provider who shares the same culture as the client. d) Assess the client's cultural views regarding hygiene and self-care.
Assess the client's cultural views regarding hygiene and self-care. Explanation: In accordance with the nursing process, assessment of the client's cultural views regarding hygiene will be necessary in order to plan care accordingly. Assessment of the skin using the Braden scale is a daily intervention for skin integrity. Incorporate the client's preferences into the plan of care which, will be identified during assessment of the cultural views. Bathing is a task that can be delegated to a UAP. Assigning a new care provider would not be done before an assessment is performed.
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? a) Give the client a damp towel for bathing. b) Check that the bathroom has a non-skid floor. c) Check that the grab bars are at shoulder level. d) Keep a bottle of bathing oil near the tub.
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 appropriate goal to include in the client's plan of care would be which of the following? a) Client will recognize the need for self-care. b) Client will participate in self-care measures by the end of the week. c) Client will consent to no hygiene measures. d) Client will verbalize the need to use to use the bedpan by the end of shift.
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
The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? a) Contact a podiatrist to care for toenails. b) Clean under toenails with a wooden orange stick. c) Use a handheld electric rotary file to reduce length of toenails. d) Clip the toenails with large clippers.
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.
A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which of the following actions will she perform? a) Refuse to bathe the client because they have not established a rapport. b) Ask several staff to be in the room for safety since the client is sometimes agitated. c) Create a calming environment with little stimuli. d) Delegate this task to someone else since it's not the nurse's responsibility to perform hygiene for clients.
Create a calming environment with little stimuli. Explanation: Bathing sometimes increases stimulation in clients who are confused or have dementia. Reducing the stimuli and providing a calm environment will decrease agitation. Turning down the lights, ensuring the adequacy of the environment where the client is being bathed and playing soft, relaxing music are possible interventions to calm the client. Nurses are responsible for the care of their clients and the staff that care for them. Delegating care of a client with dementia may require special instructions for the UAP.
A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? a) Protect the foot from blisters. b) Soak the foot in witch hazel. c) Remove ingrown toenails. d) Cut the nail straight across.
Cut the nail straight across. Explanation: The feet of older adults require special attention, because foot problems may relate to reduced peripheral blood flow. Poor circulation makes the feet more vulnerable to infection and skin breakdown, particularly after trauma. By cutting the nail straight across, the nurse can protect the toes from trauma.
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? a) Dry the cleaned areas and apply an emollient as indicated. b) Powder the area to prevent the growth of bacteria. c) Do not retract the foreskin in an uncircumcised male. d) Always proceed from the most contaminated area to the least contaminated area.
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. Perineal 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.
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. What is the priority nursing intervention? a) Offer a choice of types of soap and shampoo. b) Schedule bath in the morning or evening according to client's preferred bathing time. c) Explain that cleanliness helps to remove bacteria from skin, which can prevent infection. d) Encourage client to help with self-hygiene as able.
Explain that cleanliness helps to remove bacteria from skin, which can prevent infection. 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 is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.) a) Store the hearing aid in a very warm environment so that it will not crack. b) Use a small knife to remove cerumen that becomes embedded in the earpiece. c) Keep extra batteries on hand. d) Carefully wipe the outer surface of the hearing aid to maintain cleanliness. e) Do not get hair spray or other chemicals on the hearing aid.
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. Explanation: Extra batteries should be kept, in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.
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? a) Keep the diaper and buttocks clean and dry and apply zinc oxide. b) Apply gentian violet to the buttocks with every diaper change. c) Leave the baby's buttocks open to air for 2 hours each day. d) Change diaper as soon as it is soiled and apply cornstarch.
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 nursing student will provide a bed bath to a patient who requires full assistance with this aspect of hygiene. Which of the following actions should the student perform? a) Avoid using soap when washing the patient's face. b) Wash in a systematic way, beginning with the feet and ending with the face. c) Keep the bed in its lowest position to ensure patient safety. d) Keep the patient's perineum covered except when washing and drying it.
Keep the patient's perineum covered except when washing and drying it. Explanation: The student should aim to keep the patient's perineum covered, except when it is being washed and dried. Washing begins with the face and eyes; the student does not proceed from feet to head. The bed should be raised to the student's level of comfort, and soap may or may not be used on the face, according to the patient's preference.
Which nursing action is appropriate when providing foot care for a client? a) For diabetic clients, trim the nails with nail clippers. b) Cut off any corns or calluses. c) Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. d) Soak the feet in a solution of mild soap and tepid water.
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 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals? a) She has family and friends who help her with self-care. b) She has hot water to bathe in. c) She has motivation to participate in self-care. d) She has good mobility around her home.
She has motivation to participate in self-care. Explanation: An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.
Which documentation note regarding an assessment of eroding tooth enamel is most appropriate? a) The client is at risk for gingivitis due to eroding tooth enamel. b) The client is at risk for tartar due to eroding tooth enamel. c) The client is at risk for periodontal disease due to eroding tooth enamel. d) The client is at risk for caries due to eroding tooth enamel.
The client is at risk for caries due to eroding tooth enamel. Explanation: Eroding the tooth enamel can cause dental caries (cavities). Tartar (hardened plaque) is more difficult to remove and may lead to gingivitis (inflammation of the gums). Pockets of gum inflammation promote periodontal disease, a condition that results in the destruction of the tooth-supporting structures and bones that make up the jaw.
The nurse is overseeing the care of numerous residents of a long-term care facility. Which of the following principles should inform the care that residents receive? a) The skin of older adults is thinner and less elastic than that of younger adults. b) Hygiene is overall less important for older adults due to their reduced metabolic activity. c) Changes in the microbiota of older adults' skin create a risk for infection. d) Older adults achieve higher levels of hygiene when a caregiver provides it.
The skin of older adults is thinner and less elastic than that of younger adults. Explanation: The older adult's skin loses its ability to moisten, it is thinner, and the skin becomes less elastic; the skin is increasingly fragile and can break down easily. However, there are no widespread changes in the microbiota of older adults' skin. Hygiene is vitally important at this stage of life, and caregivers do not necessarily provide better hygiene than an active and able older adult is able to provide himself or herself.
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? a) Buy hard-bristle toothbrush to ensure proper oral hygiene. b) Take aspirin for headaches that develop. c) Use electric razor for shaving purposes. d) Reassure client that prolonged bleeding of wounds and gums is normal.
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 nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are TRUE regarding safety of the older adult while bathing? (Select all that apply) a) Use of a tub/shower seat may be necessary if balance problems are present. b) Water temperature should be monitored carefully due to decreased temperature sensation. c) Use vigorous rubbing motions when drying the skin to increase circulation. d) Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently. e) Use a long-handled shower brush or attachment to help with limited mobility.
Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility. Explanation: Several gerontological considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using non-skid mats and using a tub/shower seat. Also, care is taken to promote independence by using long-handled shower brushes or attachments to help with limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. Use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. Avoid perfumed soaps and lotions, avoid rubbing the skin when drying, and use gentle patting motions to maintain skin integrity.
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply. a) Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently. b) Use vigorous rubbing motions when drying the skin to increase circulation. c) Use of a tub/shower seat may be necessary if balance problems are present. d) Use a long-handled shower brush or attachment to help with limited mobility. e) 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. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility. Explanation: Several gerontological considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using non-skid mats and using a tub/shower seat. Also, care is taken to promote independence by using long-handled shower brushes or attachments to help with limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. Use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. Avoid perfumed soaps and lotions, avoid rubbing the skin when drying, and use gentle patting motions to maintain skin integrity.
The nurse is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.) a) Carefully wipe the outer surface of the hearing aid to maintain cleanliness. b) Do not get hair spray or other chemicals on the hearing aid. c) Store the hearing aid in a very warm environment so that it will not crack. d) Use a small knife to remove cerumen that becomes embedded in the earpiece. e) Keep extra batteries on hand.
a) Carefully wipe the outer surface of the hearing aid to maintain cleanliness. b) Do not get hair spray or other chemicals on the hearing aid. e) Keep extra batteries on hand. Explanation: Extra batteries should be kept, in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.
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? a) Check bath water temperature with hand before allowing client to bathe. b) Grab bars should be placed in the shower or tub at arm level. c) Obtain a tub or shower seat if the client has mobility issues. d) Soap should be used sparingly so the client's skin does not become overly dry.
a) Check bath water temperature with hand before allowing client to bathe. Explanation: Diminished ability to sense temperature changes may occur with aging. The temperature of bath water should be checked with the wrist, not the hand, before immersing older adults. Therefore, this statement requires intervention. The other statements are correct.
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? a) Dry the cleaned areas and apply an emollient as indicated. b) Always proceed from the most contaminated area to the least contaminated area. c) Do not retract the foreskin in an uncircumcised male. d) Powder the area to prevent the growth of bacteria.
a) 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. Perineal 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.
A 45-year-old woman has multiple sclerosis. She is able to perform most functions of self-care but recently she has been having problems with balance, which has made it hard to get dressed. Which factor is affecting this client's ability to perform self-care? a) Neuromuscular b) Cognitive c) Sensory d) Motivation
a) Neuromuscular Explanation: Proper neuromuscular functioning is imperative for motor functioning. It controls both gross and fine motor movements as well as controls normal alignment and a person's awareness of the body's spatial position.
The nurse is teaching a client about hearing aid care. Which teaching is appropriate? a) Store the hearing aid in cool environment. b) Use sandpaper to clean off hardened cerumen residue. c) Clean the hearing aid with a bleach. d) Do not change batteries by yourself.
a) Store the hearing aid in cool environment. Explanation: Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Other items listed are inappropriate for teaching.
The student nurse has observed that a newly admitted patient's toenails are long and dirty, so the student is planning to provide thorough foot care and then cut the patient's nails. What aspect of the patient's health history would contraindicate this practice? a) The patient has a long-standing diagnosis of type 1 diabetes. b) The patient was recently treated for a venous ulcer on his ankle. c) The color of the patient's nails suggests that he may have a fungal infection. d) The patient is taking anticoagulants to prevent venous thromboembolism.
a) The patient has a long-standing diagnosis of type 1 diabetes. Explanation: Due to the risk of injury, the nurse should not cut the toenails of patients who have diabetes. Fungal infections, use of anticoagulants, and recent treatment for venous ulcers do not preclude this practice.
A patient has been admitted to the geriatric unit from a long-term care facility after experiencing a fall. The patient has been anxious since admission and the nurse believes that he would benefit from a back massage. What aspect of the patient's health status would contraindicate this intervention? a) The patient suffered some fractured ribs on his left side during his fall. b) The patient has chronic obstructive pulmonary disease (COPD). c) The patient has early-stage Alzheimer disease and experiences occasional agitation. d) The patient is partially independent with his hygiene and self-care.
a) The patient suffered some fractured ribs on his left side during his fall. Explanation: A back massage would be painful for a patient with fractured ribs. Alzheimer disease, COPD, and partial independence with care are not reasons to forego a back massage.
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? a) medications listed on the client's medication administration record (MAR) b) client's allergies to soap since shaving cream is contraindicated in the hospital c) the last time shaving was performed because clients can only shave twice weekly in the hospital d) cultural views and attitudes toward facial hair and grooming
a) medications listed on the client's medication administration record (MAR) Explanation: Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? a) underneath the breasts and in between skin folds b) underneath the fingernails and toenails c) the antecubital fossa and popliteal space d) the inner and outer canthus of each eye
a) 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.
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: a) understand that his culture may influence his hygiene and ask him his preference. b) ask another nurse to assist in giving the client a complete bath every other day. c) Encourage the client to bathe daily as part of protection from infection. d) give the client a bath pan and tell him she will return when he has finished.
a) understand that his culture may influence his hygiene and ask him his preference. Explanation: Preferences for hygiene vary widely among individuals and across cultures.
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? a) "Would you prefer to use the lavender soap or the oatmeal soap to wash with?" b) "Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks." c) "When would you rather take your bath: in the morning or evening?" d) "Why don't you help wash your legs and feet?"
b) "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 community health nurse has identified that a client has head lice. When educating the client about treatment, what information should the nurse include? a) "Cut your hair as short as you're comfortable with and wash your hair carefully twice a day." b) "Make sure that you follow the shampoo instructions closely and don't exceed the recommended frequency." c) "Discard your pillowcases and any sweaters that you've worn in the last 7 days." d) "Have someone monitor your scalp daily for the next week and contact your doctor if the lice don't spontaneously resolve."
b) "Make sure that you follow the shampoo instructions closely and don't exceed the recommended frequency." Explanation: OTC pediculicidal shampoo is commonly used. If it is, patients and/or caregivers require instructions on proper use because neurological side effects may be associated with overuse of these shampoos. Lice infestations are not self-limiting and regular shampoo is ineffective. Linens and clothes must be cleaned thoroughly, but they do not normally need to be discarded.
The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse? a) "It is very uncommon for a child of this age to have bedwetting issues." b) "While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6." c) "You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening." d) "Did any of your other children have this problem?"
b) "While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6." Explanation: Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.
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? a) Partial care b) Independent showering c) The client should not be bathed d) Complete bed bath
b) 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 overseeing the care of numerous residents of a long-term care facility. Which of the following principles should inform the care that residents receive? a) Hygiene is overall less important for older adults due to their reduced metabolic activity. b) The skin of older adults is thinner and less elastic than that of younger adults. c) Older adults achieve higher levels of hygiene when a caregiver provides it. d) Changes in the microbiota of older adults' skin create a risk for infection.
b) The skin of older adults is thinner and less elastic than that of younger adults. Explanation: The older adult's skin loses its ability to moisten, it is thinner, and the skin becomes less elastic; the skin is increasingly fragile and can break down easily. However, there are no widespread changes in the microbiota of older adults' skin. Hygiene is vitally important at this stage of life, and caregivers do not necessarily provide better hygiene than an active and able older adult is able to provide himself or herself.
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply. a) Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently. b) Water temperature should be monitored carefully due to decreased temperature sensation. c) Use vigorous rubbing motions when drying the skin to increase circulation. d) Use of a tub/shower seat may be necessary if balance problems are present. e) Use a long-handled shower brush or attachment to help with limited mobility.
b) Water temperature should be monitored carefully due to decreased temperature sensation. d) Use of a tub/shower seat may be necessary if balance problems are present. e) Use a long-handled shower brush or attachment to help with limited mobility. Explanation: Several gerontological considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using non-skid mats and using a tub/shower seat. Also, care is taken to promote independence by using long-handled shower brushes or attachments to help with limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. Use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. Avoid perfumed soaps and lotions, avoid rubbing the skin when drying, and use gentle patting motions to maintain skin integrity.
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: a) combs should be washed as often as necessary. b) hair should be washed as often as necessary. c) braids should be undone every day. d) lubricants or oils should not be used on the braids.
b) 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.
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? a) "I really have limited time. Let me give you your bath right now." b) "You will be able to take your bath by yourself tomorrow when you can get up." c) "I will set up your bath for you. I will come back and help you with your bath." d) "You will need to sit up for your bath, and then I will change your bed."
c) "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? a) "A pediculicide shampoo is needed to treat this condition." b) "Lice can be spread by direct contact." c) "I will use conditioner so that the lice eggs will slide off my hair." d) "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces."
c) "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.
Which is a recommended guideline when removing contact lenses from a client's eyes? a) If the contact lenses cannot be removed, they will have to be removed by the physician under sterile conditions. b) If an eye injury is present, remove lenses immediately to avoid causing additional injury. c) Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea. d) Once removed, place both lenses in a cup and label it with the name of the client.
c) 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.
A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals? a) She has family and friends who help her with self-care. b) She has hot water to bathe in. c) She has motivation to participate in self-care. d) She has good mobility around her home.
c) She has motivation to participate in self-care. Explanation: An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.
Which of the following modifications to bathing should be implemented for a client who is incontinent? a) Use a topical antiseptic, such as povidone-iodine, in the perineal area. b) Decrease the frequency of bathing to preserve skin integrity. c) Use special perineal skin cleaners and moisture barriers. d) Perform a full bed bath each time the client has an episode of incontinence.
c) Use special perineal skin cleaners and moisture barriers. Explanation: Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation.
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: a) the preschool child should only drink milk. b) the parent should alternate bottle and tap water. c) there is a need to determine if the bottled water has fluoride. d) the preschool child should not drink bottled water.
c) 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
A nurse caring for the skin of clients of different age groups should consider which accurately described condition? a) An infant's skin and mucous membranes are protected from infection by a natural immunity. b) The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. c) Secretions from skin glands are at their maximum from age 3 on. d) An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
d) 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.
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? a) Assess the skin every day using the Braden scale. b) Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). c) Assign a care provider who shares the same culture as the client. d) Assess the client's cultural views regarding hygiene and self-care.
d) Assess the client's cultural views regarding hygiene and self-care. Explanation: In accordance with the nursing process, assessment of the client's cultural views regarding hygiene will be necessary in order to plan care accordingly. Assessment of the skin using the Braden scale is a daily intervention for skin integrity. Incorporate the client's preferences into the plan of care which, will be identified during assessment of the cultural views. Bathing is a task that can be delegated to a UAP. Assigning a new care provider would not be done before an assessment is performed.
A student nurse is providing hygiene to an older adult patient who requires care due to generalized weakness that the care team has characterized as failure to thrive. The patient is unable to ambulate but can feed herself independently if her meal tray is set up by a caregiver. When providing hygiene for this patient, which of the student's actions is most appropriate? a) Perform a full bed bath as soon as the patient awakens in the morning. b) Ask the patient's permission before washing each body region. c) Plan care so that the patient does not need to be rolled or otherwise repositioned. d) Encourage the patient to wash her arms, face, and upper body herself.
d) Encourage the patient to wash her arms, face, and upper body herself. Explanation: A general guideline when providing patient hygiene is to have the patient do as much as he or she is able to and to promote participation. The fact that the patient is able to feed herself suggests that she has sufficient use of her hands to wash her arms, face, and upper body. Repositioning is necessary in order to provide thorough hygiene. Early morning may not be the ideal time to provide hygiene, especially if the patient is drowsy. Permission is necessary, but the student does not need to elicit this with respect to each individual body part.
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. What is the priority nursing intervention? a) Schedule bath in the morning or evening according to client's preferred bathing time. b) Offer a choice of types of soap and shampoo. c) Encourage client to help with self-hygiene as able. d) Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.
d) Explain that cleanliness helps to remove bacteria from skin, which can prevent infection. 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.
A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment? a) Keratolytic shampoo b) Permethrin c) Anti-seborrhea shampoo d) Lindane
d) Lindane Explanation: The treatment choice for pediculosis corporis or pediculosis pubis is lindane. Permethrin is typically used for head lice. Neither an anti-seborrhea shampoo nor a keratolytic shampoo will be effective against lice.
Which health problem is most clearly suggestive of a history of inadequate dental care? a) Cheilosis b) Dry oral mucosa c) Alopecia d) Periodontitis
d) 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.
What type of bath is preferred to decrease the inflammation after rectal surgery? a) Bed bath b) Whirlpool bath c) Tub bath d) Sitz bath
d) Sitz bath Explanation: A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.
A nurse is educating a client on how to care for her dentures. What is a recommended teaching guideline? a) Keep dentures near you in the bedding for easy access. b) Wrap dentures in a napkin when not using them. c) Remove dentures whenever possible to rest the gums. d) Store dentures in cold water when not in use.
d) Store dentures in cold water when not in use. Explanation: Encourage the client to wear her 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. Encourage the client to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. Encourage the client to refrain from placing the dentures in the bed clothes because they can be lost in the laundry. Store dentures in cold water when not in the client's mouth. Leaving dentures dry can cause warping, leading to discomfort when worn (Holman, et al., 2005).
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)? a) shower with assist b) bag bath c) tub bath d) traditional bed bath with linen change
d) 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.
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: a) combs should be washed as often as necessary. b) braids should be undone every day. c) lubricants or oils should not be used on the braids. d) hair should be washed as often as necessary.
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: a) when the severe itching occurs. b) what linens they are using. c) when the client's last tub bath was. d) how often the client is bathing.
how often the client is bathing. Explanation: Frequent bathing for the older client can dry skin and contribute to skin breakdown.
When the nurse cleanses the client's leg during a bed bath, it will allow for: a) increased circulation. b) promotion of social interaction. c) decreased restless leg syndrome. d) assessment of pain.
increased circulation. Explanation: Bathing increases circulation and helps maintain muscle tone and joint mobility.
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? a) client's allergies to soap since shaving cream is contraindicated in the hospital b) medications listed on the client's medication administration record (MAR) c) cultural views and attitudes toward facial hair and grooming d) the last time shaving was performed because clients can only shave twice weekly in the hospital
medications listed on the client's medication administration record (MAR) Explanation: Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.
A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client? a) sit-down shower with shower chair b) bed bath c) stand-up shower d) towel or bag bath
sit-down shower with shower chair Explanation: This client is still able to bathe herself but has difficulty standing for long periods of time. In order to foster her independence and provide her with a safe bathing environment, a sit-down shower with shower chair would be most appropriate.
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? a) the importance of teaching their children adequate personal hygiene habits b) the need to destroy all clothing and bedding that the child has used c) the importance of completely finishing the prescribed treatment d) the fact that the health problem is self-limiting
the importance of completely finishing the prescribed treatment Explanation: 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 and is not self-limiting. It is not necessarily a reflection of inadequate hygiene. It is also not necessary to destroy the child's clothing and bedding.
