Ch.30 Hygiene

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." To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicatosr because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

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." The client should brush teeth twice daily, rinse with water when brushing cannot be accomplished, avoid soda of any kind, increase calcium intake, and refrain from chewing ice.

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."

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." Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.

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." Many children achieve daytime bowel and bladder control between age 2 and 3 years. They usually stay dry through the night by 4 years. but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.

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

Carefully 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 gown should be removed without disconnecting the IV equipment or cutting the gown.

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.

Which client is most at risk for foot difficulties? 80-year-old man with coronary artery disease 45-year-old woman with type 2 diabetes 91-year-old man with renal insufficiency 34-year-old woman who is paraplegic

45-year-old woman with type 2 diabetes People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.

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

51-year old with hemorrhoids

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

Use special perineal skin cleaners and moisture barriers. Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation.

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 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.

common in older adults.

Benign skin lesions such as seborrheic keratoses (tan to black raised areas)

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. The nurse can ensure the client's safety by checking for non-skid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs as they increase the risk of falls.

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

Contact a podiatrist to care for toenails.

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 helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response?

Flossing removes plaque and food debris from the surfaces of teeth that a manual or electric toothbrush may miss. The choice of unwaxed or waxed floss is personal. Waxed floss is thicker and more difficult to insert between teeth; unwaxed floss frays more quickly. The nurse should not share his or her own personal experiences, but rather, educate the patient on the need to use flossing in addition to brushing to maintain good oral hygiene.

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 Other definitions: Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition."

Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.

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? Select all that apply.

Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visiting the dentist every six months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damage the hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansing the skin regularly using lotions and creams while ensuring good cleansing of the axilla and application of deodorant and antiperspirants; and cleaning the perineal areas. Hygiene also promotes a sense of well-being and positive self-image.

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

What are recommendations that should be given to clients with poor circulation in order to prevent problems with their feet? Select all that apply.

Inspect feet daily. Avoid crossing your feet. A person with poor circulation should never use sharp instruments to cut nails as they can cause damage to the foot itself. Furthermore, they should always wear shoes to protect their feet. Soaking the feet causes them to dry out and can cause cracking.

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. Extra batteries should be kept, in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.

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.

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. Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

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 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

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 of the following solutions should the nurse use for the storage of the client's lenses after removal?

Normal saline

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

Providing a backrub before bed A backrub 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. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? R/t the inability to recognize the need to urinate or defecate R/t right-sided weakness R/t the inability to perform bathing independently R/t impaired mobility

R/t right-sided weakness Self-care deficit: Bathing is related to lack of motor skills, coordination, mental status, and endurance when performing bathing activities. Right-sided weakness is an appropriate statement about why this problem exists. A person's inability to perform bathing independently is more of a sign or symptom in the "as evidenced by (AEB)" statement of a nursing diagnosis. Related to impaired mobility is a nursing diagnosis and cannot be used as a "related/to" statement.

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. Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. 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. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her

A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. 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. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

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

Sitz bath A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.

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

Store the hearing aid in cool environment.

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?

The nurse must value and support the client becoming independent in care.

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

Use electric razor for shaving purposes. Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, and a soft bristle toothbrush will reduce bleeding during care of skin and gums.

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.

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.

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

When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

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) Assessments and wound care must be done by the RN.

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.

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

how often the client is bathing. Frequent bathing for the older client can dry skin and contribute to skin breakdown.

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

increased circulation. Bathing increases circulation and helps maintain muscle tone and joint mobility.

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.

The nurse notices multiple caries upon inspecting a client's mouth. When asked if the client has dental pain, the client responds, "No, my teeth and gums never hurt." Which structural damage does the nurse anticipate?

nerve Nerve damage has occurred if the client does not feel sensation or pain. Enamel, root, and gingiva damage do not cause decreased sensation or pain.

common in older adults.

senile lentigines (brown, flat patches on the face, hands, and forearms)

A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?

sit-down shower with shower chair

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 When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the client will shampoo the hair once and not follow through with a second washing.