Skills Hygiene

Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

Assess for pain during a bath.

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

Assess oral cavity.

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

Assess surfaces exposed to the edges of the cast for pressure areas.

A patient uses an in-the-canal hearing aid. Which assessment is a priority?

Cerumen buildup

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

Dandruff

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care?

Decreased pain sensation and increased risk of skin impairment

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best?

Defer the bath until evening and pass on the information to the next shift.

The nurse is caring for a patient who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns, but they seem to be getting worse. Which information will the nurse share with the patient?

Depending on severity, surgery may be needed to remove the corns.

When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse's action?

Less frequent bathing may be required.

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority?

Oral cavity

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

Partial bed bath

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

Turning patient's head with neck injury to side when giving oral care

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

Report sores on the patient's toes.

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area? 1. Neck, shoulders, and chest 2. Abdomen and groin/perineum 3. Legs, feet, and web spaces 4. Back of neck, back, and then buttocks 5. Both arms, both hands, web spaces, and axilla

1, 5, 2, 3, 4

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

Avoid commercial mouthwashes.

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1. Face 2. Eyes 3. Perineum 4. Arm and chest 5. Hands and nails 6. Back and buttocks 7. Abdomen and legs

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

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? 1. Roof of mouth, gums, and inside cheek 2. Chewing and inner tooth surfaces 3. Outer tooth surfaces 4. Tongue

2, 3, 1, 4

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

A patient who is diaphoretic

The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide?

Adjust the volume for a talking distance of 1 yard.

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do?

Allow the skin to air-dry.

A nurse is providing AM care to patients. Which action will the nurse take?

Applies CHG solution to wash perineum of patient with a stroke

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next?

Apply gentle, downward retraction of the ear canal.

The patient is diagnosed with athlete's foot (tinea pedis). The patient says that he is relieved because it is only athlete's foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient?

Contagious with frequent recurrences

A nurse is completing an assessment of the patient. Which principle is a priority?

Critical thinking will always be important.

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

Flossing removes plaque and tartar from the teeth.

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

From pubic area to rectum

When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?

Fungi

The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?

Halitosis

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

Head lice may spread to furniture and other people.

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

Insert an oral airway.

The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel?

Making an occupied bed

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care?

No two individuals perform hygiene in the same manner.

After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe?

Plantar warts

A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

Preschooler

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action?

Pressure reduces circulation to affected tissue.

The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve?

Prevention of amputation

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?

Retract the foreskin and return it to its natural position when done.

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

Should be done by the patient

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

Stand to the side of the patient's eye and observe the cornea.

The nurse is providing oral care to an unconscious patient. Which action should the nurse take?

Suction the oral cavity.

The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

The patient's illness may require teaching of new hygiene practices.

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

Use blunt tweezers and pull upward with steady pressure.

The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

Use gentle suction to prevent tissue damage.

The nurse is bathing a patient and notices movement in the patient's hair. Which action will the nurse take?

Use gloves to inspect the hair.

The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session?

Wash and rinse lens storage case daily.