chapter 18
15. When teaching parents how to provide oral care to their child, the nurse instructs them to: a. give bottles with juice at bedtime. b. begin dental visits after the child is 8 years old. c. allow the preschool child to floss his teeth without parental supervision. d. limit snacks to three or four per day.
ANS: D
18. Shaving with a disposable razor is contraindicated for a patient with: a. heart disease. b. diabetes mellitus. c. a head injury. d. a bleeding disorder.
ANS: D
21. The nurse assesses the patient's skin and notices an abrasion. Which of the following best describes this type of skin abnormality? a. A papulopustular skin eruption b. Rough texture on the skin surface c. Erythema and scaly, oozing areas d. A scraping away of the epidermis
ANS: D
3. The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk? a. Not provide oral hygiene because this may cause bacterial contamination of the airway. b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth. c. Not use chlorhexidine in oral care because it enhances the rate at which VAP develops. d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP.
ANS: D
4. The nurse plans to give the patient a therapeutic bath. Which of the following is considered therapeutic? a. Bed bath b. Sponge bath at the sink c. Sitz bath d. Bag bath
ANS: C
7. While washing the patient's face, the nurse should: a. wash the eyes using soap and warm water. b. wash the eyes from outer canthus to inner canthus. c. wash the eyes with plain warm water. d. use the same portion of the washcloth.
ANS: C
11. The optimal position for a female patient for the provision of perineal care is: a. prone. b. side-lying. c. high-Fowler's. d. dorsal recumbent.
ANS: D
20. The nurse is providing nail care for the patient who wants his fingernails "done." The nurse should: a. clip the fingernails gently to prevent injury. b. clean under the nails using an orange stick. c. soak the fingernails no longer than 10 minutes. d. clean under the nails using the end of a cotton swab.
ANS: C
11. _____________ is balding patches in the periphery of the hairline.
ANS: Alopecia
4. ________________ removes sweat, oil, dirt, and bacteria and helps maintain skin integrity.
ANS: Bathing
8. Tissue that surrounds the fingernail, slowly grows over the nail, and must be regularly pushed back with a soft nailbrush is known as the __________________.
ANS: Cuticle
2. The first line of defense against external injury and infection contains several thin layers of cells undergoing different stages of maturation. This first line of defense is known as the _______.
ANS: Epidermis
6. ______________ are mucous membranes with underlying supportive tissue that encircle the neck of erupted teeth to hold them in place.
ANS: Gingivae
7. Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent gum inflammation known as ____________.
ANS: Gingivitis
10. ________________ is defined as excessive growth of body and facial hair.
ANS: Hirsutism
5. The act of chewing is also known as ________________.
ANS: Mastication
COMPLETION 1. The ____________ is the largest human organ.
ANS: Skin
9. Many foot ulcers are due to repeat trauma over time, often caused by ________________.
ANS: poorly fitting shoes
12. While evaluating the hygienic care practices of a female patient, the nurse recognizes that additional instruction is necessary if the patient: a. washes the perineal area from back to front. b. washes the labia majora before the labia minora. c. avoids tension on the indwelling catheter. d. uses separate sections of the washcloth for each cleansing stroke.
ANS: A
14. The home care nurse is getting ready to help the patient prepare a tub bath. What should the nurse be sure to do? a. Instruct the patient to use safety bars. b. Use the patient's favorite bath oil for aroma therapy. c. Instruct the patient to stay in the tub no longer than 30 minutes. d. Check on the patient every 20 minutes.
ANS: A
8. When bathing a patient, which sequence is the correct approach to use? a. Wash the feet after the legs. b. Wash the eyes after the face. c. Wash the legs before the abdomen. d. Wash the back area before the extremities.
ANS: A
9. What should hygienic care of the patient with dry skin include? a. Use of moisturizers b. Use of ultraviolet light c. Application of antiseptic lotion d. Lowering of bath water temperature
ANS: A
22. The nurse is caring for a gentleman who has dry skin. When the following interventions are compared, which would be most appropriate for this patient? a. Limiting the frequency of bathing b. Using a fat-free soap for washing c. Using warm water and moisturizers d. Bathing with hot water to increase blood flow
ANS: C
23. The patient confides in the nurse that she is bothered by the fact that she has alopecia. How should the nurse respond to this information? a. Shave hair off of the affected area. b. Use permethrin. c. Offer the patient access to scarves or wigs. d. Place a drop of oil on the area.
ANS: C
2. Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP). Sources of VAP include: (Select all that apply.) a. bacteria in the oral pharynx. b. dental plaque. c. chlorhexidine rinses. d. frequent oral hygiene.
ANS: A, B
3. When taking a shower in the home setting, the patient at risk for falls may benefit from: (Select all that apply.) a. installation of grab bars. b. adhesive strips applied to the tub floor. c. addition of a shower chair or stool. d. a hydraulic lift.
ANS: A, B, C
5. The development of diabetic foot ulcers is dependent on which of the following? (Select all that apply.) a. Peripheral neuropathy b. Tissue ischemia c. Trauma to the foot d. Pain in the affected extremity
ANS: A, B, C
1. The skin, the largest human body organ, protects us from heat, light, injury, and infection and does which of the following? (Select all that apply.) a. Helps regulate body temperature. b. Stores water, vitamin D, and fat. c. Helps to sense pain. d. Prevents the entry of bacteria.
ANS: A, B, C, D
4. Patients at greatest risk for developing serious foot problems include those with: (Select all that apply.) a. peripheral neuropathy. b. peripheral vascular disease. c. pancreatitis. d. diabetes.
ANS: A, B, D
6. A patient is admitted with the diagnosis of pediculosis capitis (head lice). Proper treatment for this condition would include which of the following? (Select all that apply.) a. Use of medicated shampoo or permethrin b. Use of products containing lindane c. Combing the hair with a nit comb for 2 to 3 days after treatment d. Washing linens in cold water for 30 minutes
ANS: A, C
19. When evaluating the shaving of a patient done by a family member, the nurse determines that the technique is done appropriately when: a. long strokes are used. b. the razor is held at a 45-degree angle to the skin. c. shaving is done against the direction of hair growth. d. a cool cloth is used on the skin before the shave.
ANS: B
2. In relation to hygiene and the acute care setting, the nurse knows that which of the following statements is true? a. The disposable bath is a less desirable form of bathing than the traditional basin bath. b. The disposable bath is a more desirable form of bathing than the traditional basin bath. c. The disposable bath is more desirable for patients who can bathe independently. d. The disposable bath is not an acceptable form of bathing in the acute care setting.
ANS: B
24. The patient requires postural drainage 3 times a day. Which of the following bed positions would be most appropriate for this task? a. Fowler's position b. Trendelenburg's position c. Reverse Trendelenburg's position d. Semi-Fowler's position
ANS: B
5. What should the nurse do before starting a patient's bed bath? a. Lower the bed. b. Offer the bedpan or urinal. c. Partially undress the patient. d. Place the head of the bed in high-Fowler's position.
ANS: B
6. The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She places a bath blanket over the patient and: a. removes the gown from the arm with the IV first. b. removes the gown from the arm without the IV first. c. removes the gown after the bath to keep the patient warm. d. readjusts the IV rate before removing the gown.
ANS: B
1. The nurse is aware that normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing is known as: a. sebum. b. the epidermis. c. resident bacteria. d. the dermis.
ANS: C
10. While giving the patient a bed bath, the nurse notices a reddened area on the patient's coccyx. The nurse should: a. decrease the temperature of the bath water. b. massage the reddened area to decrease the redness. c. apply topical moisturizing agents to the area. d. ignore the redness because it will return to normal soon.
ANS: C
13. In providing perineal care for a male patient, the nurse realizes that the patient has not been circumcised. The nurse should: a. retract the foreskin aftercare has been completed. b. place the patient in prone position. c. replace the foreskin to its natural position aftercare has been provided. d. have the patient adduct his legs.
ANS: C
16. The nurse is about to provide oral hygiene to an unconscious patient. To do so, she places the patient in which position? a. Fowler's b. Semi-Fowler's c. Sims' d. Supine
ANS: C
17. A nurse recognizes that a shampoo may be contraindicated for a bed-bound patient with: a. heart disease. b. diabetes mellitus. c. a neck injury. d. a bleeding disorder.
ANS: C
3. _________________ provides an acidic coating to protect the epidermis against penetration from chemicals and microorganisms
it also minimizes loss of water and plasma proteins. ;ANS: Sebum