Chapter 31: Hygiene

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 987

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" 997

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?

Breaks in skin integrity and fungal nail infection 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. 993

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures 1022

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

use an electric razor for shaving purposes 1009

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. Which statement by the nurse should be made first?

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks" The client needs education about why bathing is important. Knowledge deficit, and fear of loss of independence and/or privacy, may be impacting the client's choice. The nurse will first provide information about the reason that bathing is important, and then assure the client that privacy will be maintained, empowerment will be given, and autonomy will be respected. 993

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" 1028

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 lines to avoid contamination." 1032

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" 1008

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" 993

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? Select all that apply.

-"I will rinse with water when I cannot brush." -"I will increase my intake of calcium." -"I will not chew ice cubes or crushed ice." 990

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

-"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." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." 994

A client expresses concern regarding the use of a bag bath. Which statement(s) by the nurse is appropriate? Select all that apply.

-"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." 999

Which action(s) does the nurse take to care for a client unable to care for dentures? Select all that apply.

-Clean the dentures with a mild commercial cleaning agent -Clean dentures with a soft toothbrush -Store dentures in water in a covered container -Keep dentures in a denture cup while carrying them to the sink -Remove upper dentures by rocking them forward 1005

A nurse is preparing the environment in a hospital room for a newly admitted client. Which actions are recommended? Select all that apply.

-Do not place soiled dressings or anything with a strong odor in the waste receptacle in the client's room. -In general, keep the room temperature between 20° and 23°C (68° and 74°F). -Avoid carrying out conversations immediately outside the client's room 1011

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select all that apply.

-Keep extra batteries on hand. -Do not get hair spray or other chemicals on the hearing aid. -Carefully wipe the outer surface of the hearing aid to maintain cleanliness. 1008

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.

-Use a tub/shower seat if balance problems are present. -Carefully monitor water temperature. -Provide the client a long-handled shower brush or attachment if experiencing limited 996

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

51-year old with hemorrhoids A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. 1000

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?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next 996

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care 994

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 nonskid floor. 996

A nurse is caring for a female client with diarrhea. What information does the nurse teach the client about perineal care and self-care?

Clean the perineal area from the front to back 1002

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to 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 while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain. 993

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 988

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. 1010

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 1018

Foot care is an essential part of routine hygiene. What is an important nursing consideration when planning foot care for clients with diabetes?

Foot care should not include soaking the feet

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. 992

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation?

Gently slide the hard lens over the cornea and remove it with gloves fingers 1006

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 1008

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps?

How often the client brushes and flosses the teeth 991

An older adult client is reporting dry, itching skin. The nurse should assess:

How often the client is bathing 998

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 995

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?

Inform the UAP that she should be wearing gloves 1030

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 1001

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 Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation. 1001

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. 1010

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?

Normal saline 1006

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that he is wearing contact lenses. What is the priority action by the nurse?

Notify the emergency department health care provider that the client is wearing contact lenses. 1007

A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:

Pediculosis 992

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

Providing a back rub before bed 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. 1001

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 stroked 1010

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include?

R/t right-sided weakness 993

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 1009

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use?

Remove and discard the cap after one use and dry the client's hair with a towel. 1009

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 989

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

Store the hearing aid in a cool environment 1008

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client?

Suction toothbrush 1026

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?

The client applies deodorant. 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 1013

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

The client should be allowed to complete as much of the bath as he can 996

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 flouride 1004

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate?

Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. 1017

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 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 bed 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. 998

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 skinfolds 1018

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:

Understand that his culture may influence his hygiene and ask him his preference 987

The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning?

Use a special cleaning solution for eye glass lenses 1006

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 bath oil in the tub to decrease dry skin 1021

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers 1021

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 1007

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

When inserting an endotracheal tube 1010

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

alopecia 991

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 1020

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation 1018

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) 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. 1009