Funds Chapter 31 Hygiene

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes

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

51-year old with hemorrhoids

The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction?

"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."

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.

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse?

using ungloved hands to remove an unconscious client's dentures

The nurse is changing a client's bedding. When removing the soiled sheets, what is the nurse's best action?

wrapped inside itself help away from the body - It is important to avoid any unnecessary contact with a client's soiled bedding to maintain the principles of infection control. The nurse must hold the bedding away from the front of his or her torso. Gloves must be worn during this task.

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 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

The nurse is caring for a client that has multiple dental caries and wants to understand the cause. Which statement by the client indicates that additional teaching is warranted?

"I will brush once every day and floss every other day."

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 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."

A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate?

"Tell me about what you do to take care of your hair."

The acute care nurse is talking with an older client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact."

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 taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?

"What are your expectations about bathing at this time?"

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 does not contribute to my well-being so I can choose to not perform hygiene." - "Hygiene measures have no affect on skin."

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."

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.

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

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

A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate? Select all that apply.

- Contact health care provider regarding diminished pedal pulses. - Contact a podiatrist.

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.

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 mobility.

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.

A sitz bath would be most appropriate for which client?

33-year-old who is one day postpartum

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.

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.

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

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.

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.

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.

There are many problems that can occur on the feet that, if found, need to be assessed further. Which common foot problem is a cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint?

Corn

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?

Create a calming environment with little stimuli.

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.

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.

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 gloved fingers.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

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

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 nurse assists a client to clean his dentures. Which action should the nurse perform?

Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

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.

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

Lindane

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

A nurse is going to bathe a client who is confined to bed. After reviewing the client's record, what does the nurse do next?

Perform hand hygiene

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

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?

Pull down on the lower lid and exert slight pressure below the lid.

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 strokes.

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.

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.

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 dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

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.

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.

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching.

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.

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.

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

Use special perineal skin cleaners and moisture barriers.

A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations?

Water should be used to clean an infant's teeth.

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

When inserting an endotracheal tube

The nurse is changing the linens of a client's bed. The client is still occupying the bed. What is the nurse's most appropriate action?

When making an occupied bed, the nurse should ensure that the siderails are up to protect the client from falls. As well, gloves should be worn for infection control.

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.

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.

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

how often the client is bathing.

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)

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

periodontitis

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

pulling the razor against the direction of hair growth

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

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