Ch. 30 (Hygiene)

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

"Hold dentures over a plastic basin or towel when cleaning them."

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."

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids

What type of bath is preferred to decrease the inflammation after rectal surgery?

Sitz bath

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:

assess the client's safety.

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)?

back massage

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should:

clean the dentures over a plastic basin or towel.

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:

hair should be washed as often as necessary.

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client's to avoid that is on the dietary tray?

jelly to go on the toast

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?

medications listed on the client's medication administration record (MAR)

A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?

sitz bath

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

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

underneath the breasts and in between skin folds

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:

Alopecia

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis

A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, "I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants." What is the best response the nurse can make?

"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained."

Which of the following modifications to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?

"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6."

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.

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)?

traditional bed bath with linen change

A parent reports that their home water is not fluoridated and questions the nurse whether it would be beneficial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?

"In the absence of fluoridated water supplies, supplementation is often recommended."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding?

-"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene measures have no affect on skin."

A client expresses concern regarding the use of a bag bath. Which statement by the nurse is most appropriate?

-"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." -"The bag bath will reduce the spread of bacteria since we are able to use separate cloths." -"Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."

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 statements from the students indicate the teaching was effective? Select all that apply.

-"When I place soiled items in the client's trash, I will remove the bag from the room when I leave." -"Always ask the client if anything is needed before you leave the room." -"It is important to keep the room at a comfortable temperature for the client."

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An outcome measure was the client will participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?

Client demonstrated bathing independently seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following?

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

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

Keep hair off the face and wash hair daily.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

The nurse is providing care to a client's eyes. What actions are appropriate when providing eye care? Select all that apply.

-Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cotton ball; or compress. -Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. -Use a different section for each stroke until the eye is clean

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select All That Apply

-Do not get hair spray or other chemicals on the hearing aid. -Keep extra batteries on hand. -Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

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. I will come back and help you with your bath."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older."

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."

A nurse is teaching a client with a burn injury regarding the function of the skin structure. Which teaching elements are appropriate to include when explaining risks for injury to the client? (Select all that apply.)

-It may be necessary to wear layers of clothing to keep war, as the skin is what helps the body regulate body temperature. -Additional caloric intake may be needed to help maintain fluid and nutritional balance to foster healing of the burned area. -Because of the burn, the skin is not able to fully the protect the body from injury and infection.

A nurse has finished providing morning care for the client. What safety measures should the nurse employ prior to leaving the client's room?

-Place the call light near the client within reach. -Place the bed in the lowest position. -Test the functioning of the bed and bed controls. -Ensure the bed is locked.

The nurse has provided instruction to the client concerning the use of the sitz bath. After the instruction the nurse is evaluating the client's understanding of the education. Which findings indicate the need for further instruction? Select all that apply.

-The client uses cool water for the treatment. -The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. -The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C).

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.

-Water temperature should be monitored carefully due to decreased temperature sensation. -Use a long-handled shower brush or attachment to help with limited mobility. -Use of a tub/shower seat may be necessary if balance problems are present. Correct response: -Use of a tub/shower seat may be necessary if balance problems are present. -Water temperature should be monitored carefully due to decreased temperature sensation. -Use a long-handled shower brush or attachment to help with limited mobility.

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

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

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

Contact a podiatrist to care for toenails.

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across.

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

Dry the cleaned areas and apply an emollient as indicated.

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?

Independent showering

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

Keep the diaper and buttocks clean and dry and apply zinc oxide.

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

Launder gowns, linens, and towels separate from other clients items.

A school nurse is conducting a teaching session for the parents of elementary students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment?

Lindane

A 45-year-old woman has multiple sclerosis. She is able to perform most functions of self-care but recently she has been having problems with balance, which has made it hard to get dressed. Which factor is affecting this client's ability to perform self-care?

Neuromuscular

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.

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.

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

Store dentures in cold water when not in use.

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures?

Store the client's dentures in water when the client is not wearing them.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in cool environment.

The nurse is caring for a client who voices concerns about the development of her 8-month-old daughter. Which finding would be a source of concern?

The child is unable to hold a spoon to attempt self-feeding.

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

Use electric razor for shaving purposes.

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention?

Use soap daily when bathing to remove debris and keep skin moist.

The client questions the nurse about the best manner to clean the ears. What should be included in the information provided to the client?

Use the twisted end of a clean washcloth and pull auricle down.

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

a thorough, mechanical cleaning