Chapter 31: Hygiene

Raise the bed to elbow height.

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?

Pull the skin taut and shave in the direction of hair growth using short strokes.

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

back massage

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)?

1) Encourage the client to rinse his or her mouth and spit. 2) Check the client's most recent platelet level after providing care.

A nurse is providing oral care to a client and observes that a significant amount of blood is coming from the client's gums. Which actions are appropriate responses? Select all that apply.

Wipe from the pubic area toward the anal area.

A nurse is providing perineal care for a female client who has a decreased level of consciousness. Which technique should the nurse employ when providing this care?

1) "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." 2) "Hygiene measures have no affect on skin." 3) "It is important to brush your teeth regularly but flossing is not necessary since it can damage

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.

Create a calming environment with little stimuli.

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform?

Check that the bathroom has a nonskid floor.

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?

sitz bath

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?

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

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:

Normal saline

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?

Independent showering

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?

She has motivation to participate in self-care.

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?

Glossitis

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

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

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

pediculosis.

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:

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

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?

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

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

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

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?

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

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? You Selected:

Providing a back rub before bed

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

Assess both eyes for contact lenses.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

"I am placing the new linens under the rolled, soiled lines to avoid contamination."

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?

The client should use an electric razor.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

1) Use a long-handled shower brush or attachment to help with limited mobility. 2) Water temperature should be monitored carefully due to decreased temperature sensation. 3) Use of a tub/shower seat may be necessary if balance problems are present.

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.

Using a tool to remove a contact lens that has adhered to the resident's eye

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)?

alopecia

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

how often the client is bathing.

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

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.

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?

1) "When I place soiled items in the client's trash, I will remove the bag from the room when I leave." 2) "It is important to keep the room at a comfortable temperature for the client." 3) "Always ask the client if anything is needed before you leave the room."

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? Select all that apply.

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

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

Contact a podiatrist to care for toenails.

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

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

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?

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

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?

51-year old with hemorrhoids

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

Keep hair off the face and wash hair daily.

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

Use a special cleaning solution for eye glass lenses

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?

Suction toothbrush

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?

Dry the cleaned areas and apply an emollient as indicated.

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

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

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

Inform the UAP that she should be wearing gloves.

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?

hair should be washed as often as necessary.

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:

Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit.

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

Brushing the dentures

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

45-year-old woman with type 2 diabetes

Which client is most at risk for foot difficulties?

periodontitis

Which health problem is most clearly suggestive of a history of inadequate dental care?

Use special perineal skin cleaners and moisture barriers.

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

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

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

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

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