NSG 310 - Foundations - Lecture 6 (Ch25 - Hygiene/Caring)

Kristen Swanson

- A composite of three studies in a perinatal unit - Defines caring as a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility - Caring is central to nursing, but not only found in nursing - Theory of Caring; 5 concepts: knowing, doing, enabling for, maintaining belief, being

dental caries

- Failure to remove plaque is primary cause of these - tooth decay - Most common infectious disease of human beings caused by Streptococcus mutans. Symptoms: often not noticeable, but range from minor disruption in the enamel of the tooth to complete destruction of the enamel and deeper layers.

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3. A school nurse teaches an adolescent about skin care related to acne. The nurse identifies that the information is understood when the adolescent says, "I should wash my face: 1. Every other day with a strong soap." 2. And then apply an oil-based ointment." 3. Thoroughly, but gently, three times a day." 4. With cool water when I shower in the morning."

bunion

A _____ is an abnormal enlargement of the joint; a painful, inflamed swelling of the bursa at the first joint of the big toe, characterized by enlargement of the joint and lateral displacement of the toe

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A nurse makes the assessment that a patient's feet are dirty. Which is the most effective nursing intervention when planning to clean a patient's feet? 1. Ask the patient to take a shower. 2. Lubricate feet with lotion to soften dirt. 3. Use an antiseptic to prevent a fungal infection. 4. Soak feet for a few minutes in a basin with soap and water.

halitosis

Also known as bad breath - results from poor oral hygiene, eating certain foods, tobacco use, dental caries, infections, and even systemic diseases such as uncontrolled diabetes or liver disease

intrapersonal, interpersonal, transpersonal

An ________ relationship is when persons are connected to themselves. An ________ relationship exists when one is connected with others and the environment. A _________ relationship exists when one is connected with God, an unseen force, or higher power.

pallor

An extreme or unnatural paleness - in a dark skinned person observe for ashen gray or yellow color

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As you are bathing a client, you notice a yellow discoloration of the sclerae of the eyes. Which of the following conditions should you suspect in this client? 1) Lack of peripheral perfusion 2) Vasodilation and inflammation 3) Decreased oxygenation of the blood 4) Impaired liver function

1 (Pruritus (itching) may lead to scratching and breaks in the skin. Maceration is softening of the skin from prolonged moisture (e.g., urinary incontinence). It makes the epidermis more susceptible to injury. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion. Acne is an inflammation of the sebaceous glands that is common among adolescents and young adults.)

As you are bathing a client, you notice some breaks in the skin on the back. When you ask the client about it, he says, "Something has been making me itch back there. I've probably just scratched it too hard." Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne

2 (Pruritus (itching) may lead to scratching and breaks in the skin. Maceration is softening of the skin from prolonged moisture (e.g., urinary incontinence). It makes the epidermis more susceptible to injury. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion. Acne is an inflammation of the sebaceous glands that is common among adolescents and young adults.)

As you are bathing an older client who has urinary incontinence, you notice that the skin of her perineal area is soft, fragile, and white. Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne

2 (As a nurse, it is not within your scope of practice to make medical diagnoses. The client should be referred to a dentist. The client should be referred to a dentist, who can proceed with the proper diagnostic tests to confirm or rule out oral cancer. Glossitis—an inflammation of the tongue—and cheilosis—a cracking and/or ulceration of the lips—are associated with vitamin B-complex deficiencies. Oral malignancies are not caused by such deficiencies. The types of lesions associated with oral malignancies are not caused by lack of tooth brushing or flossing.)

As you are providing oral hygiene for a client, you notice some white patches and ulcers on the oral mucosa. Which of the following actions should you take? 1) Explain to the client that he may have oral cancer. 2) Encourage the client to see a dentist immediately. 3) Recommend that the client increase his intake of vitamin B12. 4) Urge the client to brush his teeth and floss regularly.

tinea pedis

Athlete's foot - fungal infection of the skin - itching, burning, redness - especially between toes - moisture accumulation with unventilated shoes

complete bed bath

Bath given to clients who are totally dependent and require total hygiene care.

HS care

Before the patient goes to bed, offer to toilet them again, wash face and hands, and oral care. This is also a good time for a back massage as patients find it soothing and may help them to fall asleep. Some patients may also find a bath to be soothing and sleep promoting at this time. At this time it is also important to change soiled linens, position the patient comfortably, and ensure the call be is within reach.

caring

Behaviors that demonstrate _____: 1) Presence - Being there and being with -giving of self - especially in stressful situations - giving reassurance 2) Touch - comforting, or even eye contact - use with discretion and be aware of cultural boundaries 3) Listening - with full attention and interest - ACTIVE - not only taking in what you hear, but interpreting and understanding 4) Knowing - avoiding assumptions, focused on client - helps with clinical decision making - relationship 5) Spiritual caring - interconnectedness 6) Family Care - few live in isolation - have others that care and are concerned - an important resource

6, 5, 4, 1, 7, 8, 2, 3 (To make an occupied bed, complete the following steps: 1. Assess the patient's ability to move and need for assistive equipment and patient-handling devices. 2. Position the patient laterally near the far siderail. 3. Roll soiled linens under him. 4. Place clean linens on the side nearest you. 5. Tuck the clean linens under the soiled linens. 6. Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail. 7. Move to the other side of the bed. 8. Pull the soiled and clean linens through, and complete the linen change.)

Below are the steps for making an occupied bed. Put them in the correct order. 1Place clean linens on the side nearest you. 2Move to the other side of the bed. 3Pull the soiled and clean linens through, and complete the linen change. 4Roll the soiled linens under the patient. 5Position the patient laterally near the far siderail. 6Assess the patient's ability to move and need for assistive equipment. 7Tuck the clean linens under the soiled linens. 8Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail.

ethics of care

Concerned with the relationship between the client and nurse and the attitude of each toward the other -- Places the nurse as the client's advocate who solves ethical dilemmas by creating a relationship -- Gives priority to each client as a unique being -- essential so that professional nurses do not make professional decisions based solely on intellectual or analytical principles

PM care

Ensure that the patient is comfortable after lunch and offer assistance with toileting, handwashing, and oral care. Straighten the bed or help someone to reposition for comfort.

plantar warts

Growths/warts on the skin on the soles of the feet caused by a version of the HPV (Human Papilloma Virus). - painful

Leininger

Madeleine _____ studied caring from a transcultural perspective. - Caring is an essential human need. - Caring helps an individual or group improve a human condition. - Caring helps to protect, develop, nurture, and sustain people. - Provide care consistent with nursing's emerging science with caring as a central force

jean watson

Nursing theorist who's work has been supportive of alternative therapies in nursing; established the Center for Human Caring at the University of Colorado; describes nursing as the science of caring in her theory of caring. --Promotes healing and wholeness --Rejects the disease orientation to health care --Places care before cure --Emphasizes the nurse-client relationship -- Caring becomes almost spiritual

skin integrity

Potential risks for impaired ___ ____: - dampness - dehydration - nutritional status - insufficient circulation - skin diseases - jaundice - lifestyle and personal choices

bathing

Purpose of _____: Cleans skin** Stimulates Circulation Improves self-image Reduces body odors Promotes range of motion Provides opportunity for thorough assessment Produce a sense of well-being Promote relaxation and comfort

2 (Rationale Option 1: This will promote plantar flexion and should not be done without a toe pleat. Option 2: Maintaining functional alignment of a patient's head when making an occupied bed promotes comfort and minimizes stress to the respiratory passages and vital anatomy in the neck. Option 3: Although this is done, it is not the priority. Option 4: Although this may be done to facilitate tight sheets with minimal wrinkles, it is not the priority. In addition, there are many patients who cannot assume this position.)

Question 1. A nurse is making an occupied bed. Which nursing action is most important? 1. Securing top linens under the foot of the mattress and mitering the corners 2. Ensuring that the patient's head is supported and is in functional alignment 3. Fan-folding soiled linens as close to the patient's body as possible 4. Positioning the bed in the horizontal position

3 (Rationale Option 1: Manipulating a bottle of bath gel may be more difficult than just using a bar of soap. Option 2: Adapted toothbrushes are intended for people who have neuromuscular problems that interfere with grasping and manipulating a toothbrush, not for people with impaired vision. Option 3: Identifying the placement of supplies on the over-bed table facilitates the use of equipment by a person with impaired vision and encourages self-care. Option 4: This is a violation of patient privacy. Patients have a right to know when they are being assessed.)

Question 10. A nurse is planning to assist a patient who has impaired vision with a bed bath. What is the most appropriate nursing intervention to facilitate bathing for this patient? 1. Providing the patient with a liquid bath gel rather than a bar of soap 2. Giving the patient an adapted toothbrush to use when brushing the teeth 3. Ensuring the patient can locate bathing supplies placed on the over-bed table 4. Monitoring the patient's ability to provide self-care through a crack in the curtain

1 (Rationale Option 1: Fecal material contains enzymes that erode the skin, and urine is an acidic fluid that macerates the skin. As a result, altered skin integrity is a serious concern. Option 2: Although incontinence may contribute to low self-esteem, which may impact on a person's sexual patterns, it is not the priority. Option 3: Incontinence is unrelated to dehydration. Option 4: Although confusion may contribute to a patient experiencing incontinence, confusion is not a reaction to incontinence.)

Question 10. A patient is incontinent of urine and stool. For which patient response should the nurse be most concerned? 1. Impaired skin integrity 2. Altered sexuality 3. Dehydration 4. Confusion

1 (Rationale Option 1: Halitosis is often caused by decaying food particles and gingivitis; brushing the teeth and tongue cleans the oral cavity, which promotes healthy teeth and gums. Option 2: Although some foods can cause halitosis, it is more often caused by inadequate oral hygiene, a local infection, or a systemic disease. Option 3: Rinsing or flushing will not remove debris caught between the teeth. Option 4: Rinsing or flushing will not remove debris caught between the teeth.)

Question 11. A nurse identifies that a patient has an offensive breath. Which is the most effective intervention that the nurse should encourage the patient to do? Course Topic: Hygiene Concept(s): Nursing; Promoting HealthCognitive Level: Application [Applying] 1. Brush the teeth and tongue after meals. 2. Eat the foods that do not generate odors. 3. Rinse the mouth with mouthwash every shift. 4. Flush the mouth with peroxide and baking soda.

2 (Rationale Option 1: The cuticles should be pushed back with a washcloth or an orange stick. Option 2: An orange stick is an implement that is shaped to facilitate removal of debris from under the nails without causing tissue injury. Removal of dirt and debris decreases the risk of infection. Option 3: Hot water can cause tissue injury and should be avoided. Warm, not hot, water should be used. Option 4: Cutting the corners of the nails can cause tissue trauma and promote the development of ingrown nails. The nails should be cut or filed straight across.)

Question 11. What should the nurse do when providing fingernail care during a bath? Course Topic: Hygiene Concept(s): Critical Thinking; Skin IntegrityCognitive Level: Comprehension [Understanding] 1. Push the cuticles back with the rounded end of a metal nail file 2. Clean under the nails with an orange stick 3. First soak the hands in hot water 4. Cut the nails in an oval shape

2 (Rationale Option 1: Full or partial bed baths can be administered regardless of the activity order written by the practitioner because it is an independent function of the nurse. Option 2: A total patient assessment with an analysis of the data identifies the needs of the patient and the appropriate intervention to meet those needs. Option 3: Time has no relevance in relation to identifying what type of bed bath to administer to a patient. Option 4: Although this is a consideration, patient teaching should convince a patient what should be done to meet physical needs.)

Question 12. A nurse must make the decision to give a patient a full or partial bed bath. On what criterion does the nurse base this decision? 1. Practitioner's order for the patient's activity 2. Immediate need of the patient 3. Time of patient's last bath 4. Patient preference

1 (Rationale Option 1: Of the four options presented, the placement of a washcloth in the bottom of the sink is the most important action. This minimizes the risk of damaging the denture if the nurse should accidentally drop the denture in the sink. Option 2: The flow of water does not have to be continuous; it has to flow only when rinsing the denture cleanser off the denture after being cleaned. Option 3: It does not matter which denture is cleansed first. Option 4: Clean, not sterile, gloves are necessary to protect the nurse from the patient's oral secretions when cleaning a patient's dentures.)

Question 12. Which is most important to do when cleaning a patient's dentures? 1. Place a washcloth in the bottom of the sink. 2. Ensure a continuous flow of water. 3. Brush the upper denture first. 4. Wear sterile gloves.

1 (Rationale Option 1: Although a bath is refreshing and relaxing and may support self-esteem, this is not the primary reason for bathing. Option 2: Although friction from rubbing the skin increases surface temperature, which increases circulation to the area, this is not the primary purpose of a bed bath. Option 3: The removal of accumulated oil, perspiration, dead cells, and bacteria from the skin limits the environment conducive to the growth of bacteria and skin breakdown. An intact, healthy skin is one of the body's first lines of defense. Option 4: Although range-of-motion exercises may be performed while bathing a patient, it is not the purpose of the bath.)

Question 13. The nurse gives a bed-bound patient a bed bath. The primary reason the nurse provides hygiene to this patient is to: 1. Support a sense of well-being by increasing self-esteem 2. Promote circulation by stimulating peripheral nerve endings 3. Remove excess oil, perspiration, and bacteria by mechanical cleansing 4. Exercise muscles by contraction and relaxation of muscles when bathing

3 (Rationale Option 1: Friction, regardless of the direction of the washing strokes, in conjunction with soap and water, mechanically removes secretions, dirt, and microorganisms that decrease the potential for infection. Option 2: Friction, regardless of the direction of the washing strokes, mechanically removes dry, dead skin cells. Option 3: The pressure exerted on the skin surface by long, smooth strokes moving from distal to proximal areas also presses on the veins, which promotes venous return. Option 4: Long, smooth washing strokes that avoid a shearing force minimize skin tears.)

Question 13. When giving a patient a bed bath, the nurse washes the patient's extremities from distal to proximal. The nurse does this to: Course Topic: Hygiene Concept(s): Critical Thinking; PerfusionCognitive Level: Analysis [Analyzing] 1. Decrease the chance of infection 2. Facilitate removal of dry skin 3. Stimulate venous return 4. Minimize skin tears

1 (Rationale Option 1: Shaving in the direction of hair growth limits skin irritation and prevents ingrown hairs. Option 2: A safety razor should be held at a 45-, not 90-, degree angle to the skin. Option 3: Short, firm but gentle strokes should be used when shaving a patient. Option 4: A hot washcloth may cause a burn injury. A warm, not hot, washcloth applied to the face for several minutes before shaving helps to soften the beard.)

Question 14. The nurse is planning to shave a male patient's facial hair. What should the nurse do? Course Topic: Hygiene Concept(s): Critical Thinking; Skin IntegrityCognitive Level: Application [Applying] 1. Shave in the direction of hair growth 2. Hold the razor perpendicular to the skin 3. Use long, downward strokes with the razor 4. Use a hot, wet washcloth to wrap the face before shaving

4 (Rationale Option 1: This is unnecessary. Not everyone who wears eyeglasses has dry eyes. Option 2: A paper towel is coarse and may scratch the lenses of the eyeglasses. A soft nonabrasive cloth or chamois should be used. Option 3: Patient preference determines how long eyeglasses can be worn. Option 4: Eyeglasses should be cleaned at least once a day because dirty lenses impair vision. Warm, not hot, water is used to prevent distortion of the lens or frame, particularly if it is made of a plastic compound.)

Question 14. What should the nurse do when caring for a patient who wears eyeglasses? 1. Encourage use of artificial tears while hospitalized 2. Dry the glasses with a paper towel after cleaning the lenses 3. Limit the time that glasses are worn in an effort to rest the eyes 4. Use warm water to clean the lenses of glasses at least once a day

3 (Rationale Option 1: A patient with an amputation can still transfer to a bedside commode or ambulate with crutches to a bathroom. Option 2: When a person has early dementia, frequent reminders to perform self-toileting activities or declarative directions about toileting usually are adequate. Option 3: Discomfort due to the proximity of the fracture to the pelvic area and the limitations placed on the positioning of, or weight bearing on, the affected leg impact on a patient's ability to use a bedpan or transfer to a commode. Option 4: Although the enlarging uterus exerts pressure on the bladder causing urinary frequency and alteration of the person's center of gravity, self-toileting usually is not impaired)

Question 15. Which condition identified by the nurse places a patient at the greatest risk for impaired self-care when toileting? 1. Amputation of a foot 2. Early dementia 3. Fractured hip 4. Pregnancy

4 (Rationale Option 1: This is an incomplete outcome statement because it does not establish a timeframe when it should be achieved. Option 2: This is a nursing intervention, not a patient-centered goal. Option 3: This is a nursing intervention, not a patient-centered goal. Option 4: This is an appropriate outcome. It objectively establishes the criteria for achievement, verbalizes satisfaction with body cleanliness, and it establishes a timeframe in which it should be achieved, after morning care.)

Question 15. Which outcome associated with physical hygiene is most appropriate and should be included in a patient's plan of care? 1. Will comb hair unassisted 2. Offer pain medication before providing a bath 3. Provide clothing with Velcro® fasteners instead of buttons 4. Verbalizes satisfaction with body cleanliness after morning care

3, 5 (Rationale Option 1: A light touch is stimulating and may precipitate a penile erection; a firm but gentle touch should be used. Option 2: This action violates the principle of working from clean to dirty. The tip of the penis at the urethral meatus is washed first; bathing should then progress down the shaft of the penis toward the perineum and then the scrotum. Option 3: Repositioning the foreskin protects the head of the penis and prevents drying and irritation; if it is allowed to remain retracted, it may cause local edema and discomfort. Option 4: Cleaning should occur in the opposite direction, starting at the urinary meatus and then progressing down the shaft of the penis away from the urinary meatus. Option 5: Cleaning with a circular motion beginning at the urinary meatus and moving outward moves secretions and debris away from the urinary meatus; this lessens potential contamination of the urinary tract.)

Question 16. A nurse is cleansing the perineal area of an uncircumcised male patient. What are the most important actions by the nurse when performing this procedure? Select all that apply. 1. Handling the penis always with a light touch 2. Washing the scrotum before the shaft of the penis 3. Repositioning the foreskin after washing the penis 4. Cleansing the length of the penis down the shaft towards the glans 5. Washing the glans with a circular motion from the urinary meatus outward

2 (Rationale Option 1: This is contraindicated because it can cause permanent scarring. In addition, infected material within a pustule can spread if squeezed. Option 2: This is an acceptable practice because it removes surface oils from sebaceous glands that plug pores, which aggravate the condition. Option 3: Alcohol is caustic and drying. Washing the face with soap and warm water several times a day is adequate. Option 4: This is contraindicated. Oil-based creams will accumulate in pores and aggravate the condition.)

Question 16. A school nurse identifies that teaching about skin care for acne has been effective when an adolescent states, "I should: Course Topic: Hygiene Concept(s): Critical Thinking; Nursing Roles; Skin IntegrityCognitive Level: Analysis [Analyzing] 1. Squeeze the white heads gently and apply a topical antibiotic." 2. Wash my face several times a day with soap and water." 3. Wash with an alcohol-based facial cleanser every day." 4. Use an oil-based cream on my face after washing."

2, 3, 5 (Rationale Option 1: Denture cleaner and a soft toothbrush should be used because regular toothpaste and a firm toothbrush may be too abrasive for dentures. Option 2: This is the correct way to release the suction of lower dentures. Option 3: This is a patient-centered intervention. Option 4: Storing dentures dry can cause them to warp. Dentures should always be covered with cool water when stored in a denture cup. Option 5: This is the correct way to release the suction of upper dentures.)

Question 17. A nurse is providing oral care for a patient who is wearing full dentures. Which actions should the nurse implement when providing care for this patient? Select all that apply. 1. Clean the dentures with cool water using a firm toothbrush and toothpaste. 2. Use your thumbs to push up gently on the bottom denture at the gum line to release the suction. 3. Soak dentures overnight in a commercial dental cleanser if this is the patient's preference. 4. Store dentures in a labeled dry denture cup in the bedside drawer if the patient does not want to wear them. 5. With a gauze pad, grasp the upper denture with the thumb and forefinger and move the denture up and down to release the suction.

1 (Rationale Option 1: Hygiene is a personal matter determined by individual beliefs, values, and practices. Hygiene practices are influenced by culture, religion, environment, age, health, and personal preferences. When personal preferences are supported, the patient has a sense of control and usually is more accepting of care. Option 2: Although this information is significant in relation to the extent of self-care that may be expected, it is not the first assessment. Option 3: This is done after several other considerations and just before actually beginning the bath. Option 4: The patient's developmental level will influence how the nurse will proceed, but it is not the first assessment.)

Question 17. The nurse is planning to meet the hygiene needs of a patient. Which is the first assessment to be performed by the nurse? 1. Determine the patient's preferences about hygiene practices 2. Assess the patient's ability to assist in hygiene activities 3. Collect the patient's toiletries needed for the bath 4. Recognize the patient's developmental stage

2 (Rationale Option 1: A nurse can address a patient's pain control needs before providing care so that interventions can be performed within a tolerable pain level. Option 2: A patient with dementia may have difficulty interpreting environmental stimuli and perceive hygiene care as a threat. This may cause the patient to become frightened or anxious and resist hygiene interventions. Option 3: A patient with impaired vision generally can understand directions regarding the setup of the overbed table with hygiene equipment placed according to the numbers of a clock. Assistance by the nurse may be provided to complete the care. Option 4: A patient with impaired mobility generally can participate in hygiene care, even if it is just the ability to make choices regarding preferences. Patients with impaired mobility should be encouraged to participate to their best ability, with the balance of care provided by the nurse.)

Question 18. A nurse assesses four patients to determine their hygiene needs. The nurse should anticipate that the patient with which problem will have the greatest difficulty having hygiene needs met by the nurse? 1. Pain 2. Dementia 3. Impaired vision 4. Limited mobility

4 (Rationale Option 1: Being NPO is unrelated to physical injury, which is the state in which an individual is at risk for harm because of a perceptual or physiological deficit, a lack of awareness of hazards, or maturational age. Option 2: Being NPO is unrelated to ineffective social interaction, which is the state in which an individual is at risk of experiencing negative, insufficient, or unsatisfactory interactions with others. Option 3: Inadequate nutritional intake generally is not a concern. Most postoperative patients usually progress from a clear liquid to a regular diet in 2 to 3 days once bowel function returns. This is too short a time frame to be concerned about decreased nutritional intake. Option 4: Not drinking anything by mouth can result in drying of the oral mucous membranes and a coated, furrowed tongue. The risk for altered oral mucous membranes applies to an individual who is NPO.)

Question 18. A patient has had a nasogastric tube decompression for 3 days and is scheduled for intestinal surgery in the morning. The nurse determines that this patient is at the greatest risk for: Course Topic: Hygiene Concept(s): Critical Thinking; Digestion; Nutrition; Sensory PerceptionCognitive Level: Analysis [Analyzing] 1. Physical injury 2. Ineffective social interaction 3. Decreased nutritional intake 4. Altered oral mucous membranes

4 (Rationale Option 1: This is an acceptable practice. Excessive exposure to warm water and soap exacerbates dry skin associated with aging. Option 2: This is an acceptable practice. Soap removes the protective oils on the skin and soap residue irritates and dries the skin. Option 3: A humidified environment limits the amount of insensible loss of moisture through the skin, which helps the skin retain fluid and remain supple. Option 4: Bubble-bath preparations cause irritation and dryness of the skin because they remove essential skin surface oils. Showers are preferable to baths because baths require submersion in warm water, which is detrimental to skin hydration and resiliency.)

Question 19. A nurse identifies that additional teaching about skin care is necessary when an older adult says, "I should: Course Topic: Hygiene Concept(s): Critical Thinking; Nursing Roles; Skin IntegrityCognitive Level: Analysis [Analyzing] 1. Bathe twice a week." 2. Rinse well after using soap." 3. Humidify my home in the winter." 4. Use a bubble-bath preparation when I take a bath."

1 (Rationale Option 1: Touching a patient during a bed bath invades the person's intimate space (physical contact to 1 1/2 feet) because of the need to expose and touch personal body parts. Option 2: Although the nurse enters a patient's intimate space when obtaining vital signs, it does not involve touching the intimate parts of a patient's body and is therefore less intrusive than other intimate procedures. Option 3: This can be accomplished by remaining in a person's personal space (11/2 to 4 feet) or social space (4 to 12 feet). Option 4: Although touching a patient while ambulating invades the person's intimate space it does not involve touching the intimate parts of a patient's body and is therefore less intrusive than other intimate procedures.)

Question 19. Which nursing intervention most requires the nurse to consider the concept of personal space? 1. Providing a bed bath 2. Obtaining the vital signs 3. Performing a health history 4. Ambulating the patient down the hall

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Question 2. A nurse plans to give a patient a back rub. What is the best product the nurse can use for this intervention? 1. Rubbing alcohol 2. Betadine cream 3. Baby powder 4. Keri lotionQuestion

2 (Rationale Option 1: Although a person may have contractures, a person may still be able to provide self-care. Option 2: Being unable to wash body parts is a human response indicating that a patient is unable to provide for one's own activities of daily living, such as meeting hygiene and grooming needs. Option 3: People who are lethargic or listless generally are still able to provide for their own basic self-care needs. However, they may require frequent rest periods or more time to complete the task. Option 4: People who are legally blind are still able to provide for their own self-care needs.)

Question 2. Which human response, identified by the nurse, best supports the concern that a patient has a reduced capacity to provide for activities of daily living? 1. Presence of joint contractures 2. Inability to wash body parts 3. Postoperative lethargy 4. Visual disorders

4 (Rationale Option 1: In the high-Fowler position the abdominal organs press against the diaphragm in an obese patient, which limits respiratory excursion. The semi-Fowler position is preferred. Option 2: Administration of oxygen is a dependent function of the nurse and requires a practitioner's order unless it is needed in an emergency situation. The situation in this question is not an emergency. Option 3: A rest period every 10 minutes may be inadequate or may unnecessarily prolong the bath. This is not individualized to the patient's needs. Option 4: Evaluation of a patient's response to care allows the nurse to alter care to meet the patient's individual needs.)

Question 20. A nurse is providing for the hygiene and grooming needs of an obese patient who easily becomes short of breath when moving about. Which is the most important nursing intervention? Course Topic: Hygiene Concept(s): Critical Thinking; Nutrition; OxygenationCognitive Level: Analysis [Analyzing] 1. Maintaining the bed in a high-Fowler position 2. Administering oxygen during provision of care 3. Providing rest periods every ten minutes 4. Assessing response to activity

2 (Rationale Option 1: Strong soap can further irritate the skin. Option 2: Loose stool contains digestive enzymes that are irritating to the skin and should be cleaned from the skin as soon as possible after soiling. Option 3: The patient is mentally impaired and is unaware of needs. Option 4: This will not keep stool off the skin.)

Question 20. A patient is incontinent of loose stools and is mentally impaired. What should the nurse do to help the patient prevent skin breakdown? 1. Wash the buttocks with strong soap and water 2. Bathe immediately after a bowel movement 3. Place the call bell in easy reach 4. Put a pad under the buttocks

3 (Rationale Option 1: When the patient has peripheral neuropathy, this care should be provided by a podiatrist. Option 2: A practitioner's order is unnecessary because providing foot care is within the scope of nursing practice. Option 3: Lukewarm water is comfortable and limits the potential for burns. Drying the feet limits moisture that promotes bacterial growth. Option 4: Lotion between the toes in the dark moist environment of shoes promotes the growth of bacteria and the development of an infection.)

Question 3. The nurse is providing hygiene to a patient with peripheral neuropathy. The nurse should: 1. Seek a physician's order for foot care 2. File the toenails straight across the nail 3. Wash the feet with lukewarm water and dry well 4. Apply moisturizing lotion to the feet, especially between the toes

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Question 4. A nurse is giving a complete bed bath to a patient with an indwelling urinary catheter (Foley). What should the nurse do when cleaning the indwelling urinary catheter during perineal care? 1. Wear a face shield when washing the area. 2. Scrub up and down the tube with soap and water. 3. Wear a gown and gloves throughout the procedure. 4. Bathe around the catheter moving away from the meatus.

3 (Rationale Option 1: Vasodilation increases blood flow to the surface of the skin, which promotes, not prevents, heat loss. Option 2: Conduction is the transfer of heat between two objects in physical contact. Option 3: Convection is the transfer of heat by movement of air along a surface. Using a bath blanket limits the amount of air flowing across the patient, which prevents heat loss. Option 4: Diffusion is the mo4vement of molecules from a solution of higher concentration to a solution of lower concentration.)

Question 4. The nurse covers the patient with a cotton blanket during a bath. This is done to prevent heat loss via: 1. Vasodilation 2. Conduction 3. Convection 4. Diffusion

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Question 5. A nurse is helping a patient who has a right hemiparesis to get dressed. What should the nurse do? 1. Put the right sleeve of the gown on first 2. Keep the patient in an open-backed gown 3. Encourage the patient to dress independently 4. Leave the right sleeve off while adjusting the tie at the neck

2 (Rationale Option 1: Dental caries are caused by plaque. Therefore, brushing and flossing, not the use of mouthwash, are the most efficient ways to prevent dental caries. Option 2: An offensive odor to the breath (halitosis) can be caused by inadequate oral hygiene, periodontal disease, or systemic disease. Rinsing the mouth with mouthwash will flush the oral cavity of debris and microorganisms, which will reduce halitosis if it is caused by a localized problem. Option 3: Mouthwash flushes debris away from the teeth; it does not soften debris. Option 4: Only bactericidal mouthwashes can limit the amount of bacterial flora in the mouth; prolonged or excessive use can result in oral fungal infections.)

Question 5. A patient asks the nurse, "Why do I have to use mouthwash if I brush my teeth?" What rationale should the nurse include when responding to this question? 1. Minimizes the formation of cavities 2. Helps reduce offensive mouth odors 3. Softens debris that accumulate in the mouth 4. Destroys pathogens that are found in the oral cavity

1, 3 (Rationale Option 1: Patients can provide self-care within their abilities. When they have limitations, such as an inability to reach a body area, an activity intolerance, a decreased level of consciousness, or dementia, it is the nurse's responsibility to assist the patient regardless of the type of bath. Option 2: This is impossible if the patient is taking a tub bath or shower. Option 3: Bathing is a private matter and an invasion of personal space. The nurse provides privacy by pulling a curtain, closing a door, and keeping the patient covered as much as possible. These interventions maintain the patient's dignity. Option 4: Providing a bed bath is within the scope of nursing practice, so a practitioner's order is unnecessary. An order is necessary for a tub bath or shower because it requires an activity order and is therefore a dependent function. Option 5: There is no need for a call bell when a patient is taking a tub bath or a shower because it is unsafe to leave a patient alone.)

Question 6. The nurse considers the actions that are common to both a bed bath and a tub bath. Select all that apply. 1. Helping the patient wash parts that cannot be reached 2. Exposing just the part of the body being washed 3. Providing for privacy throughout the bath 4. Obtaining an order from the practitioner 5. Ensuring that the call bell is in reach

1

Question 6. What should the nurse do when washing the penis of an uncircumcised patient? 1. Retract the patient's foreskin completely. 2. Wash down the shaft toward the meatus. 3. Always employ a very light touch. 4. Use a rubbing motion.

2 (Rationale Option 1: Although this might be done to promote the body mechanics of the nurse, it is not a necessity. Option 2: The temperature of bath water should be between 110°F and 115°F to promote comfort, dilate blood vessels, and prevent chilling. A lower temperature can cause chilling, and a higher temperature can cause skin trauma. Option 3: Although a mitt retains water and heat and prevents loose ends from irritating the skin, it is not as essential as other factors that relate to patient safety. Option 4: Although the height of the bed should be adjusted to promote the nurse's body mechanics, it is not as essential as other factors that relate to patient safety.)

Question 7. A nurse is giving a patient a bed bath. Which nursing action is most important? 1. Lower the 2 side rails on the working side of the bed 2. Ensure that the bath water is at least 110°F 3. Fold the washcloth like a mitt on the hand 4. Raise the bed to the highest position

4 (Rationale Option 1: The legs are cleaner than the perianal area, and if washed last they will become more contaminated from microorganisms and fecal material from the rectum. Option 2: The feet are cleaner than the perianal area, and if washed last they will become more contaminated from microorganisms and fecal material from the rectum. Option 3: The axillae are cleaner than the perianal area, and if washed last they will become more contaminated from microorganisms and fecal material from the rectum. Option 4: The perianal area has fecal material and microorganisms that can contaminate other parts of the body; therefore, the perianal area should be washed last.)

Question 7. The nurse is providing a bed bath for a bed-bound patient. What should the nurse wash last? 1. Legs 2. Feet 3. Axillae 4. Rectum

1 (Rationale Option 1: Mouth breathing, oxygen use, unconsciousness, and debilitation, among other conditions, can lead to dry oral mucous membranes. The nurse should provide oral hygiene with saline rinses frequently to keep the oral mucosa moist. Option 2: Mouthwash contains astringents that can injure sensitive, delicate dry mucous membranes. Option 3: Oral hygiene four times a day is inadequate for a patient with a dry mouth, and a water pick is contraindicated because the force of the water can injure delicate dry mucous membranes. Option 4: Lemon and glycerin swabs are counterproductive because their use can lead to further dryness of the mucosa and an alteration in tooth enamel.)

Question 8. A nurse is caring for a patient with an excessively dry mouth. Which nursing action is most important when providing mouth care for this patient? Course Topic: Hygiene Concept(s): Critical Thinking; DigestionCognitive Level: Application [Applying] 1. Providing oral care every 2 hours 2. Rinsing frequently with mouthwash 3. Cleansing 4 times a day with a water pick 4. Swabbing with a sponge-tipped applicator of lemon and glycerin

4 (Rationale Option 1: Friction from firm, long strokes used during rinsing increases circulation; however, it is not the reason for rinsing. Option 2: Local massage and repositioning every 2 hours, not rinsing, prevent pressure ulcers. Option 3: A back rub and positioning in functional alignment, not rinsing, promote rest and comfort. Option 4: Rinsing flushes the skin with clean water, which removes debris and soap residue.)

Question 8. What is the main reason why the nurse rinses the patient after washing with soap and water during a bed bath? 1. Increase circulation 2. Minimize pressure ulcers 3. Promote rest and comfort 4. Remove residue and debris

4 (Rationale Option 1: Bedrest does not cause dry hair. Malnutrition, aging, and excessive shampooing cause dry hair. Option 2: Bedrest does not cause oily hair. Infrequent shampooing causes oily hair. Option 3: Bedrest does not cause hair to split. Excessive brushing, blow drying, and coloring cause hair to split. Option 4: Bedrest causes matted, tangled hair because of friction and pressure related to the movement of the head on a pillow.)

Question 9. Which common problem with the hair should the nurse anticipate when patients are on complete bedrest? Course Topic: Hygiene Concept(s): Critical Thinking; Skin IntegrityCognitive Level: Comprehension [Understanding] 1. Dry hair 2. Oily hair 3. Split hair 4. Matted hair

1 (Rationale Option 1: Asking about the patient's personal preferences allows the nurse to individualize the patient's care. Personalizing a patient's care demonstrates respect and caring. Option 2: This is premature. Raising the height of the bed may not be necessary if the patient can provide hygiene care independently. Option 3: The linens should be changed after hygiene care because they can get wet and soiled during care. Option 4: It is not necessary to eat breakfast before a.m. care. Breakfast can be eaten before or after a.m. care, depending on the patient's preference.)

Question 9. Which should the nurse do first before initiating a.m. care with a patient? Course Topic: Hygiene Concept(s): Nursing; Nursing RolesCognitive Level: Application [Applying] 1. Ask the patient about preferences. 2. Raise the bed to working height. 3. Change the linens on the bed. 4. Feed the patient breakfast.

5, 3, 7, 1, 4, 6, 2

Sequence of bathing: Put the following in the correct sequence: 1 Chest and abdomen 2 Genitalia/Perineal area 3 Face & neck 4 Legs and feet 5 Eyes - inner to outer canthus 6 Back and buttocks 7 Axillae, arms, hands

T

T/F: The normal nail is transparent, smooth, and convex.

1

The nurse sits with the client and holds the client's hand as his pain decreases. This situation is an example of the following caring practice: 1Nursing presence 2Assessment 3Knowing the client 4Empowering

1, 3, 4 (Feedback 1: ADLs, such as taking a bath or shower, washing hair, or brushing and flossing teeth, promote comfort. Feedback 2: Encouraging as much self-care as possible promotes independence, not dependence. Feedback 3: ADLs improve self-image. Feedback 4: ADLs decrease infection and disease. Feedback 5: Encouraging as much self-care as possible promotes, not decreases, activity. Feedback 6: Encouraging as much self-care as possible promotes self-esteem, not anxiety.)

Which of the following are effects of a client performing personal hygiene and activities of daily living (ADLs) for herself? SELECT ALL THAT APPLY. 1) Promotes comfort 2) Promotes dependence 3) Improves self-image 4) Decreases infection and disease 5) Decreases activity 6) Increases risk of anxiety

2 (Assessing for overall grooming and cleanliness would require observation of the client, not obtaining a health history. The purpose of obtaining a health history as part of assessing a client's self-care abilities is to identify underlying illness, injury, or disease that might contribute to a self-care deficit or affect tolerance of hygiene procedures. Assessing for tactile disturbances would require a physical assessment for sensory disturbances, not obtaining a health history. Pain assessment would not require obtaining a health history.)

You are assessing a client's self-care abilities and begin by obtaining a health history. Which of the following is the correct rationale for this action? 1) To determine overall grooming and cleanliness 2) To identify underlying illness, injury, or disease that might contribute to a self-care deficit 3) To assess for tactile disturbances 4) To assess pain

1

You are caring for a client who can participate in dressing herself but requires assistance because of a severe tremor in her hands resulting from Parkinson's disease. She does not use any assistive devices. Which of the following would be the most accurate diagnosis for this client? 1) Dressing Self-Care Deficit (2) related to hand tremors secondary to Parkinson's disease 2) Self-Care Deficit (dressing) related to Parkinson's disease secondary to hand tremors 3) Parkinson's disease related to hand tremors as evidenced by Dressing Self-care Deficit (3) 4) Dressing Self-Care Deficit (1) related to Parkinson's disease as evidenced by hand tremors

2, 3, 5, 6 (Feedback 1: The patient's family history of multiple sclerosis would not be pertinent to communicate to the NAP before assistance with a bath, shower, or toileting. Feedback 2: Before assigning a NAP to assist with a bath, shower, or toileting, give instructions about the patient's limitations and restrictions and the amount of assistance necessary. Feedback 3: Relate to the NAP the use of any assistive devices (e.g., cane, walker, or gait belt). Feedback 4: The patient's medication allergies would not be pertinent to communicate to the NAP before assistance with a bath, shower, or toileting. Feedback 5: Describe any obstacles present, such as drainage tubes, catheters, IV tubing, or bandages, and explain how to maintain them during bathing or toileting. Feedback 6: Mention any observations to make during the procedure and why the observations are important (e.g., skin condition; presence of lesions; areas of special concern over bony prominences and under abdominal folds and breasts; presence, appearance, and amount of urine or stool; or the need to collect a specimen).)

You are delegating the bathing of a client to a nursing assistive personnel (NAP). About which of the following should you give instructions to the NAP? SELECT ALL THAT APPLY. 1) Patient's family history of multiple sclerosis 2) Mobility limitations 3) Use of a walker 4) Medication allergy 5) Presence of intravenous (IV) tubing 6) Skin condition

4 (A bag bath is a modification of the towel bath, in which you use 8 to 10 washcloths instead of a towel and bath blanket. They are moistened with water (preferably sterile, filtered, or distilled) or a pH-balanced, no-rinse soap. They are then warmed and each part of the patient's body is cleansed with a fresh cloth. A towel bath is a modification of the bed bath in which you place a large towel and a bath blanket in a plastic bag, saturate them with a warmed, commercially prepared mixture, and use them to bathe the patient. A bed bath is for patients who must remain in bed but who are able to bathe themselves. You will assist by placing the bath supplies on the bedside stand or overbed table. A basin and water bath is a modification of the bed bath, in which you use a disposable basin with water or pH-balanced, no-rinse soap, lotion, and washcloths to provide a bath if the patient refuses the prepackaged bath or if the patient is grossly soiled (i.e., large amounts of blood or feces).)

You are preparing to bathe an older adult who is incontinent and who is unable to bathe himself. As you remove his diaper, you see that his perineal area is covered with feces. Which type of bath would be most appropriate to give this client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath

1

You are providing eye care to a patient who is in a coma. Which of the following should you do? 1) Lubricate the eyes with saline every 2 to 4 hours. 2) Use a protective eye shield to keep the eyes open. 3) Instill eye ointment in the upper lids. 4) Occasionally stimulate the client's blink reflex to help lubricate the eye.

1 (Older adults may find it necessary to bathe only every 2 or 3 days, use less soap, and increase the use of skin moisturizers. To reflect caring, expand your understanding of the concept of hygiene to respect and accommodate each person's preferences and differences whenever possible. Don't insist on bathing her daily, which could dry out her skin. Respect her preference of soap; a deodorant soap may be too harsh for her skin. Respect her preference to bathe twice weekly.)

You are providing hygiene care for an older client who requires assistance with activities of daily living. When you ask her how often she typically bathes, she replies, "A couple of times per week." How should you respond to the client? 1) Agree to bathe her twice per week. 2) Insist on bathing her daily for health reasons. 3) Agree to bathe her twice a week, but insist on using a substantial amount of deodorant soap. 4) Encourage her to bathe only once a week and to use a skin moisturizer instead.

1, 4 (Feedback 1: Inspect the feet daily, using a mirror to view all surfaces. Feedback 2: Avoid soaking the feet (if you are diabetic, or if there is decreased circulation to the feet). Feedback 3: Do not cut or file callused areas. Feedback 4: Check between the toes for cracks or redness. Feedback 5: Avoid open-toed shoes, sandals, high heels, and thongs. They do not protect the feet. Feedback 6: Do not put tape or over-the-counter corn medicines or pads or other medications (e.g., hydrogen peroxide) on the feet.)

You are teaching a client with diabetes how to care for her feet. Which of the following guidelines should you give her? SELECT ALL THAT APPLY. 1) Inspect the feet daily using a mirror to view all surfaces. 2) Soak the feet daily. 3) File down callused areas. 4) Check between the toes for cracks or redness. 5) Wear open-toed shoes when possible to expose the feet to air. 6) Apply over-the-counter corn medicines to the feet.

1

You moisten 10 washcloths with sterile water and a pH-balanced, no-rinse soap, warm them up, and then cleanse each part of a client's body using a fresh cloth. Which type of bath are you giving the client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath

1, 4, 5, 6 (Feedback 1: Pain severely limits the person's ability and motivation to perform ADLs. Feedback 2: Hypertension, which typically has no symptoms, would not likely prevent a client from performing his or her own ADLs. Feedback 3: Diabetes mellitus would not likely prevent a client from performing his or her own ADLs. Feedback 4: Limited mobility (e.g., from joint and muscle problems, injury, weakness, fatigue, surgery, prescribed bedrest, or pain) makes it difficult to perform hygiene activities. Rheumatoid arthritis is a chronic, progressive disease involving inflammation of the joints and leading to disability. Feedback 5: Sensory deficits, such as poor vision caused by macular degeneration, diminish a person's ability to perform hygiene measures safely and independently. Safety is a priority for patients with sensory deficits. Feedback 6: Patients experiencing altered reality states, such as psychoses, delusions, or hallucinations, may dress inappropriately for the weather or the situation and have poor hygiene practices. Patients with schizophrenia often experience hallucinations.)

You work with patients with a variety of conditions, many of whom you must assist with activities of daily living (ADLs) during their stay in the hospital. You should be prepared to provide hygiene assistance to patients with which of the following conditions? SELECT ALL THAT APPLY. 1) Severe pain resulting from third-degree burns 2) Stage I hypertension 3) Diabetes mellitus 4) Rheumatoid arthritis and limited mobility 5) Macular degeneration 6) Schizophrenia

dry

____ skin tends to crack, burn, itch

contact

____ touch is a form of nonverbal communication that provides comfort and security -- might involve holding a hand or back rub.

hygiene

_____ : --is a set of practices conducive to health --is preventative care --provides comfort and sense of well-being --is necessary for comfort, safety, and well-being. and Includes: -- Such functions as bathing, toileting, general body hygiene, and grooming -- Care of skin, hair, nails, teeth, oral and nasal cavities, eyes, ears, and perineal/genital areas

task oriented

_____-_____ touch is used when performing a procedure or task.

spiritual

_______ health is achieved when a person can find a balance between their life values, goals and belief symptoms and those of others. -- offers a sense of interpersonal and transpersonal connectedness.

protective

_______ touch is used to protect a client, for example to prevent or stop a fall.

noncontact

_______ touch refers to eye contact.

self help bath

assistance in difficult to wash areas

cyanosis

bluish coloring of the skin caused by decreased peripheral circulation or decreased oxygenation of the blood. - may be r/t cardiac, pulmonary, or peripheral vascular problems - in dark skinned person, best seen by examining conjunctivae, tongue, buccal mucosa, and palms and soles - dull dark color

corn

cone shaped thickening of the epidermis caused by continuous pressure (eg improperly fitting shoes) over bony prominences - such as the toe joints - They are often painful

partial bed bath

consists of bathing only body parts that would cause discomfort if left unbathed (hands, face, axillae, & perineal area). Includes washing back and giving back rub. **are given to those unable to reach all body parts.

acne

inflammation of the sebaceous glands that is common among adolescents and young adults

plaque

invisible, destructive bacterial film that builds up on the teeth eventually leading to destruction of tooth enamel

AM care

is often provided after clients have breakfast, although it may be provided before breakfast. It usually includes providing for elimination needs, a bath or shower, perineal care, back massages, and oral, nail, and hair care. Making a clients bed is part of morning care.

pruritus

itching - may lead to scratching, breaks in the skin

pressure ulcers

lesions caused by tissue compression and inadequate perfusion

excoriation

loss of the superficial layers of the skin caused, for example, by scratching and by the digestive enzymes in feces

ingrown toenail

occurs when toenail grows deeply into nail groove and penetrates surrounding skin; caused by external pressure from tight shoes, trauma, improper nail trimming, infection

erythema

redness of the skin usually due to capillary dilation and/or inflammation - In dark skinned person may need to palpate for areas of increased warmth

abrasion

rubbing away of the epidermal layer of the skin, especially over bony prominences - often caused by friction or shearing forces that occur when a patient moves or is moved in bed

early morning care

shortly after the patient wakes up, assisting them with toileting and then providing comfort measures to refresh the patient and prepare them for breakfast, including washing the face and hands and providing mouth care.

maceration

softening of the skin from prolonged moisture (eg urinary incontinence) - makes epidermis more susceptible to injury

calluses

thickening of the outer layers of the skin at points of friction or pressure - similar to corns but cover a wider area and are not painful

burns

type of traumatic injury caused by thermal, chemical or radioactive agents

jaundice

yellow discoloration of the skin - occurs in patients with impaired liver function - best seen in sclera of the eyes