Prep U's - Chapter 31 - Hygiene (TF)

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

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

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

"I will set up your bath for you, and you can use the call button to let me know if you need help." The nurse must value and support the client becoming independent in care.

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

"I am placing the new linens under the rolled, soiled linens to avoid contamination."; when making an occupied bed, it is important for the nurse to use clean linen and make the near side of the bed first. Then, the nurse places the bottom sheet in the center of the bed. Next, the nurse opens the sheet and pulls the bottom sheet over the corners at the head and foot of the mattress. Next, the nurse pushes the sheet toward the center of the bed, pulling it taut and positioning it under the old linens to avoid contaminating the new linen. In the image, the position of the client is for making an occupied bed, not for assessing the skin as the old linen is covering the client's skin. The nurse is not tucking the draw sheet tightly; it is the fitted (bottom) sheet that is displayed in the image.

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

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist." Soap should not be used on a daily basis since it can have a very drying effect on the skin. Therefore, the nurse should re-educate the family on this information. Thus, the family should check the temperature of bath water before immersing an older adult client because with aging there is a diminished ability to sense temperature changes. Grab bars and shower chairs are a safety measure to assist the client in and out of the tub or shower.

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?

"Those are senile lentigines and are common in older adults." Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratoses and this doesn't address the client's concern of brown patches on their face and arms.

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?

A back massage can be delegated to a UAP. Assessments and wound care must be done by the RN.

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

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

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

A full bed bath every day may cause excessive dryness in many older adults, and a continent client may not require a bath every day. If dry skin is a problem, water and skin lotion or bath oil may be used on alternate days with a bed bath. Do not use bath oil in tub water, as it can cause tub surfaces to become slippery. Bed baths should not be avoided altogether but simply given every other day.

The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide?

A furuncle (boil) is a raised pustule, usually in the neck, axillary or groin area that feels hard and painful. The nurse will teach the client to keep hands away from the infection lesion, to use separate cloths and towels from the rest of the family, to wash hands thoroughly before and after applying medication, and to launder personal bath items in hot water and bleach to prevent the transmission of infection. The nurse will not teach the client to squeeze the lesion, nor will tell the client that the skin disorder is noninfectious or that nits may be present on hairs under the axillae.

The nurse is providing oral care to a unconcious client. Which piece of equipment will the nurse use to individualize care for this client?

A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.

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 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 tub 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.

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

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.

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

Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, in place of a safety razor, and a soft-bristled toothbrush will reduce bleeding during care of skin and gums. The client should not be advised to take aspirin, buy a hard-bristled toothbrush, or explain that prolonged bleeding is normal.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care?

Assist the client in dressing oneself after offering alternative techniques; Self-care refers to a person's ability to perform primary care functions in bathing, feeding, toileting, and dressing without the help of others. Nurses play an important role in helping clients learn or relearn self-care. The ability for the client to independently perform appropriate self-care improves a person's health status and emotional well-being. After a CVA, an adult client would need help relearning how to dress, not learning to dress. Encouraging the client to use assistive devices is not an appropriate intervention for dressing and undressing. Suggesting a family member assist may not be appropriate and cause the client to feel embarrassed or helpless. Likewise, having the client return demonstration is not appropriate as the client knows visually how to do this task, but is unable to perform dressing themselves.

The nurse is assisting a 56-year-old female who has undergone a mastectomy with her morning care. Which action by the client requires further teaching by the nurse?

Clients who have undergone surgery for a mastectomy should avoid the use of deodorants or antiperspirants postoperatively because they act to close sweat glands and can cause skin irritations. In others, the use of these products may be contraindicated due to personal or cultural values. Independence with hygiene measures is encouraged and cosmetics may be used for multiple reasons, including self-image enhancement in women. There are several bath preparations and a bag bath is convenient and beneficial to the client's skin.

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

Clients with diabetes will be more susceptible to infection from breaks in skin integrity and nail problems. People with diabetes are more susceptible to fungal toenails and foot injury because of poor circulation and lack of feeling. A bunion, a bony bump on the joint at the base of the big toe, is not specific to clients with diabetes and can be caused by wearing tight, narrow shoes. Cold feet can be caused by things other than diabetes, such as atherosclerosis. Red inflamed joint of the big toe with reports of pain can indicate the client is suffering from gout and may not be attributable to diabetes.

A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate?

Clients with diabetes, impaired circulation, and/or thick nails should be seen by a podiatrist to evaluate and care for nails. The nurse should contact the health care provider to assess the finding of diminished pedal pulses.

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?

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

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

File, rather than cut the nails; Clients who have diabetes, impaired circulation, or thick nails are at risk for vascular complications secondary to trauma. The nails should be filed rather than cut. It is not appropriate to clip the toenails with large clippers, use a handheld electric rotary file, or clean under the toenails with a wooden orange stick.

The nurse manager is preparing to educate newly hired nurses about fingernail hygiene. Which education is appropriate?

Fungal nail infections can result from application of artificial fingernails, whether acrylic or gel. No type of nail treatment or polish should be used. The nurse should wash hands frequently, cleaning under nails each time to prevent transmission of infection.

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

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. When not worn continuously, dentures should be stored in water in a covered container. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.

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

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

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

Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Skin barrier products, such as those containing zinc oxide, are used to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces. Application of one of these products forms a thin layer on the surface of the skin to repel potential irritants.

A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student?

Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms.

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

No mouthwash, breath freshener, ointment, or paste replaces a thorough, mechanical cleaning of the oral cavity. Following the steps for cleaning the mouth thoroughly is more important than the agent used.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

Which client is most at risk for foot difficulties?

People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk, but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.

Which intervention(s) does the nurse use in perineal care for a postoperative uncircumcised client?

Proper perineal care for the uncircumcised male client includes starts with placing the client in a side-lying position and then cleaning the penile shaft from the tip downward toward the scrotum, retracting foreskin and washing the glans penis, and cleaning the tip of the penis from the urethral meatus outward in a circular motion. Cleaning the client's genitals after the buttocks, with client in a supine position both risks contamination of the client's skins with fecal matter and makes it difficult to clean the anal area with the client laying on the area to be cleaned.

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

Pull the skin taut and shave in the direction of hair growth using short strokes; The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms; 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.

Which action(s) is appropriate to safely bathe an older adult client?

Several considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using nonskid mats and using a tub/shower seat. Also, care is taken to promote independence by providing the client with long-handled shower brushes or attachments if there is limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. The nurse should 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. The nurse should avoid using perfumed soaps and lotions, as well as avoid rubbing the skin when drying. The nurse should use gentle patting motions to maintain skin integrity.

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?

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

She has motivation to participate in self-care.; an internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

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

Skinfold areas may be sources of odor and skin breakdown if not cleaned and dried properly. The antecubital fossa (inner portion of arm) and popliteal space (behind the knee) are not skinfold areas that require cleaning. The eyes, toenails, and fingernails are not sources of odor.

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

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

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?

The client is at risk for caries due to eroding tooth enamel; The accumulation of food debris, especially sugar adn plaque may eventually erode the tooth enamel which will cause caries.. 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.

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

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

The health care environment can be very stressful for a client. During an orientation session of nursing students, the nursing instructor teaches students how to minimize a stressful environment. Which statement from the students indicates the teaching was effective?

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

The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?

The priority intervention is to check the plan of care for hygiene directives or orders. This ensures continuity of care. The other interventions can be carried out subsequent to this, after the nurse has determined if there are specific hygiene directives in place.

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety?

This client is still able to bathe by oneself but has difficulty standing for long periods of time. In order to foster independence and provide the client with a safe bathing environment, a sit-down shower with shower chair would be most appropriate.

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care?

To prevent aspirations, use only small amounts of water and an oral suction device.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)?

Using a tool to remove a contact lens that has adhered to the resident's eye; A contact lens that presents a challenging removal should be addressed by the nurse rather than delegated to UAP. This is due to the potential for injury to the resident's eye. All of the other listed tasks can be safely delegated to UAP.

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care?

Warfarin is in a class of drugs known as anticoagulants, which interrupt the clotting ability of blood. The use of anticoagulants increase the risk of bleeding. Periodontitis is inflammation of the gums and may be associated with swollen, painful, or bleeding gums. Chemotherapy can result in sensitive mucous membranes and bleeding gums. Platelets are blood cells that are necessary for adequate clotting. When the level of platelets are decreased the blood is not able to clot effectively and the risk of bleeding increases. An unwitnessed fall may be a sign of unnoticed blood loss or bleeding, but it is not likely to be the cause of oral bleeding. Shortness of air, or dyspnea on exertion, is not associated with increased bleeding, especially of the gums. Beta-blockers such as carvedilol are not associated with increased risk for bleeding. The qualities of mental status--intact, altered, or decreased--have no bearing on tissue integrity or the body's ability to clot effectively.

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?

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.

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis?

When a client is receiving radiation, she develops stomatitis, an inflammation of the oral mucosa. The inflammation is painful and makes eating difficult. The priority diagnosis is the potential for impaired nutrition. There is no indication that confusion is a problem. Stomatitis is a form of impaired skin integrity, but nutrition is a priority. Infection is a less likely consequence.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.

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

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

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

When inserting an endotracheal tube; If the client is brought to the hospital with a full beard, do not shave his beard without consent unless it is an emergency situation, such as insertion of an endotracheal tube. For this procedure, shave only the area needed and leave the rest of the beard. A nebulizer can be used effectively with a beard in place and a tangled beard can usually be untangled.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

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 client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week; 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.

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that:

hair should be washed as often as necessary; 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. For clients who style their hair in small braids, the braids are not undone for shampooing and may need to have a lubricant or oil applied daily to prevent hair strands from breaking. Combs should be kept clean for overall hygiene.

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

pulling the razor against the direction of hair growth; When shaving a client, it is appropriate to wash the skin prior to shaving and to rinse the razor after each stroke. It is also appropriate to apply direct pressure if the skin is nicked from the razor. It is not appropriate to shave against the direction of hair growth. Shaving with the direction of the hair reduces the potential for irritation of the skin.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

raise the bed to elbow height; proper bed height helps reduce back strain while performing the procedure. A protective pad keeps the sheets from getting wet. Placing a drain container under the shampoo board prevents a mess on the floor. Closing the curtains around the bed and closing the door to the room provides for client privacy.

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?

the importance of completely finishing the prescribed treatment

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

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