Chapter 40 Hygiene

A nurse bathes an older adult patient using a pack of cotton cloths that are premoistened with a surfactant cleaner and an emollient. Which bath is being given to the patient? 1 Bag bath 2 Tub bath 3 Sponge bath 4 Shower bath

1 A bag bath involves using several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient to clean a patient. A tub bath involves immersion of the patient in a tub of water. A sponge bath sink involves bathing the patient using a sponge along with a bath basin or sink with the patient sitting in a chair. In a shower bath, the patient sits or stands under a continuous stream of water.

A 27-year-old patient is brought to the emergency department in an unconscious state with an injury to the neck and head. On assessment, the nurse finds blood-tinged secretions in the patient's oral cavity. The nurse immediately raises the head of the patient's bed to 30 degrees and turns the patient to the side. The nurse also applies a neck collar, arranges for suctioning of the oral secretions, and immediately notifies the health care provider. Which intervention carried out by the nurse should have been avoided? 1 Turning the patient to the side 2 Applying a neck collar to the patient 3 Notifying the health care provider immediately 4 Assessing the patient in the absence of the health care provider

1 A nurse should be very careful in positioning a patient who has sustained head and neck injuries. Excessive mobilization of this patient, such as turning the patient to the side, should be avoided to prevent any further injury to the spine. Injury to the spine can affect the respiratory and circulatory centers and also cause paralysis; therefore, the patient should not be moved. The nurse can apply a cervical collar if trained in doing so. It is very important to notify the health care provider immediately for further instruction. The presence of a health care provider is not necessary for assessment and providing immediate care.

A patient is diagnosed with meningitis. The nurse performs an assessment of the gag reflex and the corneal reflex, and conducts Rinne's and Weber's tests. Which test helps determine whether the patient is at risk for aspiration? 1 Gag reflex 2 Corneal reflex 3 Rinne's test 4 Weber's test

1 A patient with severe meningitis may have altered consciousness, which may impair the swallowing reflex. The gag reflex is tested by placing a tongue blade on the back half of the patient's tongue. Testing for a gag reflex helps to determine whether a patient's swallowing reflex is intact, which is necessary to prevent aspiration. The gag reflex also helps to determine whether the patient needs a suction apparatus and, if so, which type of suction apparatus is needed. The corneal reflex is used to assess the function of the eyes. Rinne's and Weber's tests are used to determine auditory function.

Which type of bath is most appropriate for a patient with an inflamed and swollen rectum, perineum, and genital area? 1 Sitz bath 2 Tub bath 3 Therapeutic bath 4 Complete bed bath

1 A sitz bath is encouraged for a patient with an inflamed and swollen rectum, perineum, and genital area. A tub bath may exacerbate the patient's symptoms. A therapeutic bath is a whirlpool bath used to remove infected or necrotic tissue from wounds. A complete bed bath is administered to an entirely dependent patient in bed.

While assessing a patient's oral cavity, the nurse observes cracked lips. What does the nurse document in the patient's health record? 1 Cheilitis 2 Halitosis 3 Glossitis 4 Gingivitis

1 Cracked lips are called cheilitis. Foul-smelling breath is called halitosis. Inflammation of the tongue is called glossitis. Inflammation of the gums is called gingivitis.

While caring for a patient with partial dentures who has dental caries, the nurse observes that the patient's gums have lost vascularity and tissue elasticity. Which risk does the nurse suspect? 1 The patient's dentures cannot fit properly. 2 The patient may have significant bleeding. 3 The patient cannot chew food properly. 4 The patient may develop periodontal disease.

1 Gums lose vascularity and tissue elasticity due to lack of attention to oral care; this may cause the patient's dentures to fit poorly. Ulcerations or trauma can result in significant bleeding of the oral cavity. A patient could still chew food if the gums lost vascularity and elasticity because this condition may not affect the teeth. Improper oral care results in periodontal disease.

While assessing a patient, the nurse finds inflamed gums. What would the nurse document in the patient's medical chart? 1 Gingivitis 2 Xerostomia 3 Dental caries 4 Periodontitis

1 Inflammation of gums is known as gingivitis. Dry mouth is called xerostomia. Dental carries is tooth decay produced by the interaction of food and bacteria. Periodontitis causes shrinkage of the gums and loosening of the teeth.

Which symptom often changes a patient's gait? 1 Pain 2 Burning 3 Swelling 4 Numbness

1 Pain often changes a patient's gait. A burning sensation in the feet is a symptom of Morton's neuroma. Swelling of the feet is known as bunions. Numbness in the feet is another symptom of Morton's neuroma.

While assessing a patient, the nurse observes that the patient has a dry cornea. What may be the cause of this condition? 1 Paralysis of the trigeminal nerve 2 Hormonal and nutrient deficiencies 3 Ulcerations and trauma of the head region 4 Strong stimulation of the sympathetic nervous system

1 Paralysis of the trigeminal nerve eliminates the blink reflex, which causes corneal drying. Hormonal changes and nutritional deficiencies may affect the patient's hair characteristics. Ulcerations and trauma of the head region can cause significant bleeding in the oral cavity. Strong stimulation of the sympathetic nervous system may cause xerostomia.

A licensed practical nurse is caring for a patient under the supervision of a registered nurse. Which action if made by the licensed practical nurse requires a need for further teaching? 1 Rubbing the patient's skin 2 Removing fingerrings 3 Bathing the patient with warm water 4 Giving the patient a blanket

1 Rubbing the patient's skin can create friction and lead to a loss of stratum corneum. This loss may cause the development of pressure ulcers. Finger rings should be removed while caring for patients to avoid accidental injury to the patient's skin. Multiple blankets should not be used, because they can interfere with heat loss through radiation and conduction. Bathing the patient with excess cold water is inappropriate.

A patient reports scaling and cracking of the skin between the toes and soles of the feet. Upon closer assessment, the nurse finds small blisters containing liquid. How might the nurse expect the primary health care provider to treat this patient? 1 Application of griseofulvin 2 Application of salicylic acid 3 Burning with an electrical spark 4 Freezing with solid carbon dioxide

1 Scaling and cracking of the skin between the toes and soles of the feet indicates athlete's foot (tinea pedis), a fungal infection characterized by small blisters containing liquid. Application of griseofulvin is used to treat athlete's foot. Salicylic acid, burning with an electrical spark, and freezing with solid carbon dioxide are ways to treat plantar warts, not athlete's foot.

The nurse is attending to a patient who cries, screams, and shouts while bathing. What step should the nurse take while bathing this patient? 1 Give a bag bath. 2 Give a traditional bath. 3 Give a shower 4 Postpone the bath for two days

1 The bag bath can help reduce negative and aggressive behaviors during bathing because it is the most efficient bathing method. It is also possible to keep the patient covered and comfortable during the process. The patient is aggressive and may not be cooperative for a traditional bath or shower. Postponing the bath for two days would compromise the personal hygiene of the patient.

Which position is indicated for providing perineal care to a male patient? 1 Supine position 2 Fowler's position 3 Trendelenburg's position 4 Dorsal recumbent position

1 The supine position is recommended for providing perineal care to male patients. Patients are placed in Fowler's position so the nurse can insert nasogastric tubes. Trendelenburg's position is recommended for patients with poor peripheral perfusion. The dorsal recumbent position is recommended for female patients requiring perineal care.

The nurse is helping a female patient bathe. As the nurse is about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action should the nurse take initially? 1 Explain to the patient that, because of her symptoms, the nurse needs to observe the perineal area. 2 Insist that the nurse is supposed to complete the care. 3 Honor the patient's request to complete her own perineal care to avoid any embarrassment. 4 Ask the patient if a family member can complete the care instead.

1 The symptoms of burning and discomfort indicate a problem. It is the nurse's responsibility to perform an assessment to note any vaginal or urethral discharge, skin irritation, and odors. It is not safe to let embarrassment cause the nurse to overlook hygiene needs and the diagnosis of problems. Providing information and teaching often encourages patient cooperation.

The nurse is performing a routine health checkup of a patient who is addicted to drugs and has had multiple sexual partners. The nurse finds lice in the patient's scalp hair and pubic hair. What is the next best option for lice treatment if chemicals fail? 1 Remove the lice manually. 2 Shave the scalp hair. 3 Shave the pubic hair. 4 Apply normal shampoo

1 There are many chemical treatments for lice. When these treatments fail, the next best option is to manually remove the lice. Shaving the hair of the scalp or pubic area is not necessary for permanent removal of lice. While removing the lice, the nurse should apply medicated shampoo. A normal shampoo would not be useful in removing the lice.

A group of nursing personnel plan to take an unstable and weak patient out of a tub. Which equipment is beneficial in this situation? 1 Lift equipment 2 Linen bag 3 Nail clippers 4 Disposable bath mat

1 Weak or unstable patients need extra assistance in getting out of a tub. The nursing staff should have lift equipment handy to transfer the patient from a bathtub. A linen bag, nail clippers, and a disposal bath mat are equipment used to perform nail and foot care.

A registered nurse (RN) is evaluating the actions of a nursing student who is performing foot and nail care. Which of the nursing student's actions indicates the need for further learning? 1 Rewarming the water after 3 minutes 2 Placing the basin on a bathmat or towel 3 Allowing the patient's feet and fingernails to soak for 10 to 20 minutes 4 Cleaning under the fingernails with a plastic stick while the fingers immersed in water

1 While performing nail and foot care, the nurse should fill the wash basin with warm water and test the water temperature. After soaking the patient's feet and fingernails, the nurse should rewarm the water after 10 minutes. The basin is placed on the bath mat or towel. The patient's feet and fingernails should be soaked for 10 to 20 minutes. While the fingers are immersed in the basin, the fingernails are gently cleaned with a plastic stick.

Which statement is correct about types of baths? Select all that apply. 1 A partial bed bath is indicated in a patient with pain. 2 A sponge bath is indicated in a patient sitting in a chair. 3 A complete bed bath is given to patients who are very ill. 4 A complete bed bath offers a reduction in bathing time. 5 A tub bath is given to remove infected tissue from wounds

1, 2, 3 A partial bed bath includes bathing selected areas and is indicated in a patient with pain. A sponge bath involves bathing a patient using a bath basin or sink while the patient sitting in a chair. A complete bed bath is given to a patient who is bedridden and ill. A bag bath offers an ease of use, reduction of the bathing time, and promotes patient comfort. A therapeutic bath is given to a patient to for smoothing effects and in for the promotion of healing.

A registered nurse has delegated the task of providing a patient with oral care to the nursing assistive person (NAP). What instructions will the nurse give the NAP? Select all that apply. 1 "Report any pain in the patient." 2 "Position the patient so as to avoid aspiration." 3 "Report excessive coughing in the patient." 4 "You can consider bleeding of the gums to be a normal reaction." 5 "Know that choking is common after oral hygiene."

1, 2, 3 While delegating the task of providing oral care, the registered nurse should direct the nursing assistive person (NAP) to report pain in the patient, position the patient in such a way as to avoid aspiration, and to report excessive coughing in the patient. Bleeding and choking are not normal or common and should be reported.

In which order should the nurse complete the steps of washing a patient's abdomen? Correct 1. Place the bath towel lengthwise over the chest and abdomen Correct 2. Fold the bath blanket down to just above the pubic region Correct 3. Lift the bath towel with one hand Correct 4. Stroke from side to side, giving special attention to the skin folds of the abdomen Correct 5. Keep the abdomen covered between washing and rinsing

1, 2, 3, 4, 5 First, the nurse should fold the bath blanket down to just above the pubic region. This action is followed by lifting the bath towel with one hand. Next, the nurse should bathe the abdomen, giving special attention to the umbilicus and skinfolds with strokes from side to side. Finally, the nurse should keep the abdomen covered between washing and rinsing.

The nurse is teaching the patients in a nursing home about good oral hygiene practices. What are the advantages of good oral hygiene practices? Select all that apply. 1 Stimulates the appetite 2 Reduces the risk of stroke 3 Reduces the risk of nursing home-acquired pneumonia 4 Helps with control of blood sugar in diabetes 5 Relieves discomfort from unpleasant odors and tastes

1, 2, 3, 4, 5 Good oral hygiene is required to maintain health and prevent diseases. The mouth is the first part of the gastrointestinal system; any malfunction or disease of the mouth can affect other systems. Maintaining oral hygiene can help stimulate the appetite. Poor oral hygiene causes proliferation of bacteria in the oral cavity and bleeding of gums, which can cause an infection to come into direct contact with the blood. This may spread infections to other parts of the body. Evidence has proven that good oral health also reduces the risk of stroke and nursing home-acquired pneumonia. In patients with diabetes, good oral hygiene helps control blood sugar levels. Brushing massages the gums and relieves discomfort resulting from unpleasant odors and tastes.

The nurse is instructed to remove the gown from a patient who has a running intravenous (IV) line on the left arm. Arrange the steps in the correct order. Correct 1. Remove the right arm of the gown. Correct 2. Remove the left arm of the gown. Correct 3. Remove IV tubing from pole. Correct 4. Slide IV bag and tubing through arm of patient's gown. Correct 5. Re-hang IV bag and check flow rate

1, 2, 3, 4, 5 To remove the gown from a patient with an intravenous (IV) line, the nurse should remove the arm of the gown from the arm without the IV line first. Therefore, the nurse should remove the right arm of the gown first. Then the nurse should remove the second arm of the gown. While doing so, the IV line and IV bag should be taken out from the gown without disconnecting the IV line from the IV cannula. Finally, the IV bag should be re-hung on the pole. The flow rate should not be disturbed in this process, but it should be checked and corrected if required.

The nurse is assessing an older adult's oral health. How should the nurse assess the oral cavity? Select all that apply. 1 Observe for cleanliness. 2 Use olfaction to assess halitosis. 3 Apply sterile gloves to palpate any tender areas. 4 Inspect the mouth for color, hydration, texture, and lesions. 5 Inform the health care provider if there is any abnormality.

1, 2, 4 While assessing oral health, the nurse should observe for cleanliness since poor oral hygiene leads to various oral diseases. Olfaction should be used to assess halitosis. Inspecting all areas of the mouth carefully for color, hydration, texture, and lesions helps to assess health of the oral cavity. Sterile gloves are not required for assessment of oral cavity. Applying clean gloves to palpate any tender areas or lesions prevents introducing infection to the oral cavity. An appropriate intervention is to notify the health care provider of any abnormality.

A child has head lice, and the nurse is giving the family instructions on appropriate hygiene care. Which instructions is he or she likely to give to the family? Select all that apply. 1 "Clean and boil the comb." 2 "Use tweezers to catch the lice." 3 "Screen for lice twice a week." 4 "Clean the patient's clothes in warm water." 5 "Dip the comb in a cup of water to remove the lice."

1, 2, 5 Hygiene care for head lice includes cleaning the comb with an old toothbrush and boiling the comb. Tweezers or a comb can be used to catch lice. The comb should be dipped in a cup of water between each passing to remove lice. The remaining instructions are inaccurate. Combing and screening for lice should be done every day, but just twice a week. The patient's clothes should be cleaned in hot, not warm, water.

Which statements are correct regarding the perineal care of a male patient? Select all that apply. 1 Gently clean the shaft of the penis 2 Clean the scrotum by having the patient abduct his legs 3 Clean the urethral meatus using a back to front motion 4 Clean the anus and buttocks area using a back to front motion 5 Retract the foreskin of the patient if the penis is uncircumcised

1, 2, 5 The shaft of the penis must be cleaned gently because vigorous cleaning may cause an erection. The abduction of the legs provides easier access to the scrotal tissues. If the patient is uncircumcised, the nurse should retract the foreskin. The urethral meatus should be cleaned in a circular motion to prevent microorganisms from entering the urethra. The anus and buttocks area must be cleaned using a front to back motion to prevent infection.

A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior, such as screaming and hitting during the bath. Which techniques would make the bathing experience less stressful for both the nurse and the patient? Select all that apply. 1 Allow the patient to perform as much of the care as possible. 2 Start by washing the face. 3 Try an alternative to traditional bathing, such as the bag bath. 4 Use restraints to prevent the patient from injuring self or the nurse. 5 Be quick to keep the bath as short as possible.

1, 3 Patients with cognitive impairment may respond to bathing by acting out aggressively. Studies have indicated a number of triggering events, including washing the face first. The bag bath has been shown to result in a lower incidence of aggressive behavior than traditional bathing. Use of restraints is not warranted and can actually lead to injury, because the patient often fights against the restraints. Cognitively impaired patients respond better when the nurse uses a gentle approach and avoids rushing.

The nurse is monitoring an older adult patient who has undergone coronary artery bypass graft (CABG) for blocked blood vessels of the heart. Which dermatological findings in the patient indicate healthy skin? Select all that apply. 1 Pink color 2 Symmetry 3 Supple skin 4 Warm skin 5 Hair follicle density

1, 3, 4 Changes in color, thickness, temperature, and hydration of the skin are various dermatological presentations that help the nurse to differentiate between healthy and unhealthy skin. A pink color indicates healthy skin. Suppleness of the skin indicates that the skin is well hydrated, and warm skin indicates adequate circulation. Symmetry and hair follicle density do not indicate significant pathological change in postoperative patients.

The nurse is teaching a group of caregivers about methods of skin care. Which instructions should the nurse include in the teachings? Select all that apply. 1 Use emollients. 2 Use alkaline soaps. 3 Bathe regularly. 4 Keep bed and linens dry. 5 Use many blankets and bed coverings.

1, 3, 4 Emollients soften skin and prevent moisture loss. Bathing helps to remove excess body secretions. Keeping bed linens and clothing dry helps to prevent development of pressure ulcers. Constant exposure of skin to wet linen may cause skin maceration, which impairs skin integrity and promotes infection and ulcer formation. Alkaline soaps tend to neutralize the protective acid condition of skin, promoting bacterial growth. Excess blankets or bed coverings interfere with heat loss through radiation and conduction.

A patient reports dry and flaky skin. During an assessment, the nurse notices a loss of protective oils from the skin. What are possible reasons for the patient's condition? Select all that apply. 1 Bathing frequently 2 Using alkaline soaps 3 Perspiring excessively 4 Using hot water frequently 5 Using excessive deodorants

1, 4 If the patient bathes and uses hot water frequently, the skin may become dry and flaky and it may lose protective oils. Using alkaline soaps will neutralize the protective acid condition of the skin. Excessive perspiration can harbor microorganisms. The use of excessive deodorants may cause chemical irritation.

The visiting nurse arrives at the home of an older adult who has diabetes. Which instructions should the nurse give to the patient regarding oral hygiene measures? Select all that apply. 1 "Use a soft-bristled toothbrush." 2 "Replace dentures frequently." 3 "Brush your teeth at least once a day." 4 "Brush your teeth for a minimum of 90 seconds." 5 "Rinse your mouth at least four times a day with saline water."

1, 4, 5 A patient with diabetes is more susceptible to oral health problems. The nurse should instruct the patient to use a soft-bristled toothbrush to avoid any injuries to the gums. Teeth should be brushed for at least 90 seconds to clean the oral cavity properly, and the mouth should be rinsed at least four times a day to remove debris present between the teeth. For proper oral health, teeth should be brushed at least twice daily. Dentures should not be replaced frequently. Keeping dentures in place could promote healing of stomatitis.

Which factors impair salivary secretions? Select all that apply. 1 Dehydration 2 Glistening of the mucosa 3 Significant bleeding 4 Effects of medication 5 Exposure to radiation

1, 4, 5 Factors that impair salivary secretions include dehydration, effects of medication, and exposure to radiation. Normal oral mucosa glistens. Significant bleeding occurs when there is any ulceration or trauma in the oral cavity.

While caring for a patient, the nurse instructs the patient to perform oral hygiene at least twice a day. Which conditions is the nurse preventing the patient from developing? Select all that apply. 1 Gingivitis 2 Xerostomia 3 Ulcerations 4 Dental caries 5 Periodontal disease

1, 4, 5 Performing oral care at least twice a day and flossing reduces the risk of gingivitis, dental caries, and periodontal disease. Xerostomia might not be reduced by performing regular oral care. Ulcerations are not reduced by performing regular oral care.

The nurse provides dietary instructions to a patient to help to prevent tooth decay. Which of the patient's statements indicate effective learning? Select all that apply. 1 "I will eat apples regularly." 2 "I will eat cakes frequently." 3 "I will drink coffee regularly." 4 "I will eat candies frequently." 5 "I will drink orange juice regularly.

1, 5 Drinking orange juice prevents tooth decay because acidic fruits reduce plaque formation. Apples are rich in fiber, which does not cause tooth decay. Cakes, coffee, and candies are rich in artificial sugars that increase the risk of tooth decay.

While caring for a patient, a nurse finds that the patient is untidy and is uninterested in hygiene. What should the nurse do in this situation? Select all that apply. 1 Educate the patient about hygiene. 2 Help the patient develop new hygiene practices. 3 Force the patient to change the hygiene practices. 4 Assess the patient's personal preferences regarding hygiene. 5 Assess the patient's ability to perform daily hygiene practices.

1, 5 Patients who appear untidy or uninterested in hygiene should be educated about the importance of hygiene. The nurse should also determine the patient's ability to perform daily hygiene. New hygiene practices should be developed for patients who are unable to perform regular hygiene practices due to illness or impairment. Patients should not be forced to change hygiene practices unless the practice affects the patient's health. Knowing the patient's personal preferences promotes individualized care.

A registered nurse teaches a group of nursing students about critical thinking. Which statement if made by the nursing student indicates the need for further learning? 1 "All factors should be considered during assessment." 2 "Clinical judgments and decisions should be made before anticipating the information." 3 "The nursing knowledge should be integrated with the knowledge from other disciplines." 4 "It requires the synthesis of knowledge, experience, and information gathered from the patients."

2

What is the priority concern when providing oral hygiene for a patient who is unconscious? 1 Thoroughly brushing all tooth and oral surfaces 2 Preventing aspiration 3 Controlling mouth odor 4 Applying local antiseptic such as chlorhexidine

2 Although thorough and effective cleaning is needed, measures to prevent aspiration of oral secretions or cleaning agents into the lungs take priority, because aspiration can lead to lower respiratory infections.

A nurse provides bath care using chlorhexidine gluconate (CHG) wipes. Which statement about the use of these wipes requires correction? 1 Chlorhexidine gluconate wipes decrease the time for bathing. 2 Chlorhexidine gluconate wipes are contraindicated in bariatric patients. 3 Chlorhexidine gluconate wipes are indicated for providing bathing care for older adult patients. 4 Chlorhexidine gluconate wipes are found to reduce the incidence of hospital-acquired infections.

2 Chlorhexidine gluconate (CHG) wipes are indicated in patients with morbid obesity. The use of CHG wipes decreases bathing time and reduces the occurrence of hospital acquired infections. Older adults are typically prescribed CHG wipes for bath care.

Which action is contraindicated in a patient with peripheral vascular disease? 1 Filing the fingernails 2 Clipping the toenails 3 Using a soft cuticle brush 4 Applying lotion to the feet

2 Clipping the toenails is contraindicated in patients with peripheral vascular disease. Filing the nails is preferred to clipping. Applying lotion prevents the skin from becoming too dry. Using a soft cuticle brush reduces the incidence of inflamed cuticles.

Which statement is true about the development stage of adolescents? 1 Sebaceous glands become less active, resulting in acne. 2 In girls, the skin becomes soft with increased vascularity. 3 The growth and maturation of the integument decreases. 4 In boys, the skin becomes darker due to decreased thickness.

2 In girls, estrogen secretion causes the skin to become soft and thicker with increased vascularity. During adolescence, the growth and maturation of the integument increases. Sebaceous glands become more active, resulting in acne. Boys will not experience a reduction in skin thickness as they develop.

The nurse caring for a male patient observes the nursing assistive person (NAP) performing perineal care. Which observed action indicates a need for further teaching for the NAP? 1 The NAP used clean gloves. 2 The NAP did not retract the foreskin before cleansing. 3 The NAP used the clean portion of a washcloth for each cleansing wipe. 4 The NAP used a circular motion to cleanse from urinary meatus outward.

2 Secretions collect beneath the foreskin and can promote bacterial growth if not removed. Using clean gloves, clean portions of the washcloth for each cleansing wipe, and using a circular motion to cleanse from the urinary meatus outward are all appropriate measures while performing perineal care.

A registered nurse teaches a nursing student about bed-making. Which statement made by the nursing student indicates the need for further teaching? 1 "I should raise the bed before changing the linen." 2 "I should shake soiled linens before replacing them." 3 "I should straighten any linen that is loose or wrinkled throughout the day." 4 "I should place soiled linens in special linen bags before placing them in a hamper."

2 Shaking soiled linens will transmit infection; therefore, this action should be avoided. The nurse should raise the bed to an appropriate height before changing the linen. This action prevents bending or stretching over the mattress. Linens should be straightened throughout the day. Soiled linens should be placed in a special linen bag to avoid the transmission of infection.

Which instruction should the registered nurse give to the nursing assistive personnel who is providing a complete bed bath to a patient? 1 Wear latex-free gloves if necessary 2 Avoid massaging the reddened area under the skin folds 3 Wash the patient's face with chlorhexidine gluconate solution 4 Disconnect the intravenous pump tubing while removing the patient's gown

2 Special care should be taken to clean the skin folds. Massaging the areas under the reddened skin folds may increase skin inflammation and redness. The nurse should always use latex gloves to prevent soiling of hands and transmission of infections while caring for a patient. Chlorhexidine gluconate solution contains antimicrobials, so it should not be used to wash the patient's face. The nursing assistive personnel should use clear water or mild soap and water instead. Intravenous pumps should not be disconnected while removing the patient's gown becauseit may worsen the patient's health condition.

What is the name of the crescent-shaped white area present in the nail body? 1 Cuticle 2 Lannula 3 Nail bed 4 Nail groove

2 The crescent-shaped white area of the nail body is called the lannula. The nail groove is hidden by the cuticle. The nail bed is a thin layer of the epithelium under the nail. The root of the nail is located in the skin at the nail groove.

The nurse is assisting an elderly patient with a bath. Which action by the nurse is appropriate? 1 Make sure the water is soapy 2 Apply lotion to chapped skin 3 Use hot water to bathe the patient 4 Apply the maximum amount of mild soap

2 While assisting the elderly patient in a bath, the nurse should apply lotion to chapped skin to moisturize the skin. If the water is soapy, it should be changed. The water used for the patient should be warm. Using hot water makes the skin dry by removing natural oils. The nurse should apply the minimal amount of mild soap to the patient to prevent skin irritation and dryness.

Which action performed by the nurse is inappropriate while implementing care to patients in a health care facility? 1 Providing care with a flexible attitude 2 Being judgmental and confident while providing care 3 Planning rest periods while caring for a patient who is tired 4 Developing new ways of providing care to patients with impaired self-care ability

2 While providing hygienic care, the nurse should be nonjudgmental and confident. The nurse should provide care with an attitude of flexibility because of variations in the patient's physical status and hygiene practices. The nurse should pace activities and plan rest periods while caring for a patient who is tired to prevent exhaustion. The nurse should also develop new ways of providing care to patients with impaired self-care ability.

While performing foot and nail care, the nurse observes tissue edema on the patient's feet. Which predisposing conditions might have contributed to this? Select all that apply. 1 Stroke 2 Heart failure 3 Renal disease 4 Diabetes mellitus 5 Peripheral vascular disease

2, 3 Heart failure and renal diseases increase the risk of tissue edema, particularly in dependent areas such as the feet. Cerebrovascular accidents, such as a stroke, cause leg weakness or paralysis. This may result in altered walking patterns, which causes increased friction and pressure on the feet. Peripheral vascular changes associated with diabetes mellitus cause reduced blood flow to peripheral tissues.

A patient with diabetes comes to the clinic for a routine check-up. What should the nurse check for when assessing the patient's feet? Select all that apply. 1 Palpate the pulse of the brachial artery. 2 Palpate the pulse of the posterior tibial artery. 3 Assess whether sensation is intact. 4 Inspect the toenails and trim them if required. 5 Assess the range of motion of the foot and ankle.

2, 3, 4 Feet require a good blood supply. To assess this, the nurse should check the posterior tibial pulses and the dorsalis pedis. The feet of a diabetic patient are prone to injuries due to decreased sensation caused by peripheral neuropathy. Therefore, the nurse should assess the sensation to light touch, pinprick, and temperature. Long toenails can cause injury and thus should be checked and trimmed if required. (In some care settings, a health care provider's order may be required for trimming the nails.) The brachial artery is on the arm and checking its pulsations is not required in this patient. Range of motion is not affected in diabetics.

The patient wears full dentures during the day and removes them overnight. The patient's usual denture care includes taking the teeth out once a day to brush.. The nurse is concerned that the patient might be at risk for developing denture-induced stomatitis. Which points should the nurse include in a teaching plan for denture care? Select all that apply. 1 Remove dentures overnight once a week while they soak in a cleansing bath. 2 Do not wear damaged or poorly fitting dentures. 3 Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. 4 See dentist regularly. 5 Rinse dentures after meals. 6 Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.

2, 3, 4, 5 Denture stomatitis is caused by wearing dentures that do not fit well, wearing dentures overnight, and practicing poor denture-cleaning habits that promote the buildup of the yeast Candida albicans. The development of denture stomatitis is prevented by interfering with the buildup; the patient should remove the dentures overnight; clean properly; and prevent damage to the oral mucosa, gums, and palate.

Which equipment used while making an unoccupied bed is considered optional? Select all that apply. 1 Washcloth 2 Drawsheet 3 Clean gloves 4 Bottom sheet 5 Waterproof pads

2, 3, 5 Applying a drawsheet is optional while making an unoccupied bed. Clean gloves may be used only if the linen is soiled; gloves are considered optional equipment while making a bed. Placing waterproof pads on the bed is also optional. Washcloths or paper towels are used to clean the mattress with the help of an antiseptic cleanser. This is mandatory while making a patient's bed. The bottom sheet is the most important equipment used while making a patient's bed

The nurse is caring for a patient who has reduced sensation in both feet. Which should the nurse do? Select all that apply. 1 Avoid cleaning the feet until an order from the health care provider is received. 2 Wash the feet with lukewarm water and then dry well. 3 Apply moisturizing lotion to the feet, especially between the toes. 4 File the toenails straight across. 5 Advise the patient that going barefoot will help keep skin on the feet dry and healthy.

2, 4 Lukewarm water limits potential for burns in the patient with reduced sensation. Drying limits moisture that promotes growth of microorganisms. Always clip and file nails straight across (when ordered). An order is not needed to clean feet. Lotion between toes could cause maceration. Patients with reduced sensation should wear shoes and clean, dry socks at all times; they should never go barefoot.

While making a bed for a postoperative patient, which nursing actions indicate a need for further education? Select all that apply. 1 Making the bed when it is unoccupied 2 Placing extra linens in the patient's room 3 Folding the top covers back in an open bed 4 Tucking or mitering the top sheets and spread 5 Folding the bedspread to one side or to the bottom third of the bed

2, 4 The nurse should avoid bringing excess linens to the patient's room. Tucking or mitering should also be avoided while making a patient's bed. Making the bed when it is unoccupied is beneficial. The nurse should fold the top covers back in an open bed. Folding the bedspread to one side or to the bottom third of the bed promotes the easy transfer of the patient.

The nurse is caring for a 16-year-old patient with acne. Which instructions should be included when teaching skin care to the patient? Select all that apply. 1 Avoid washing hair each day. 2 Avoid squeezing the acne. 3 Use cosmetics. 4 Use prescribed topical applications. 5 Eliminate foods that aggravate the condition from diet.

2, 4, 5 Squeezing or picking acne can spread the infected material within the pustule and may also lead to permanent scarring. Prescribed topical antibiotics are used for severe forms of acne. Certain foods that aggravate acne should be avoided. Hair should be washed daily to remove excess oil. Cosmetics should be used sparingly because oily cosmetics or creams accumulate in pores and tend to make the condition worse.

During bathing, a patient who is in a supine position experiences shortness of breath and labored breathing with a respiratory rate of 30. In which position should the bed be placed? 1 Trendelenburg's. 2 Reverse Trendelenburg's. 3 Fowler's. 4 Semi-Fowler's.

3 Fowler's upright sitting position facilitates breathing by allowing for full expansion of the chest and lungs. Although reverse Trendelenburg's position raises the head of the bed, it is a straight tilt position and is not likely as comfortable as the more supported Fowler's position.

A patient complains of pain between the toes, which is aggravated when walking with shoes on. On examination, the nurse finds that the shoes are ill-fitting. The nurse also finds a cone-shaped, round, and raised lesion between the toes. Which instruction would be appropriate for the patient? 1 Wear oval corn pads. 2 Apply salicylic acid. 3 Soak the feet in warm water. 4 Soak the feet in antiseptic solution

3 Friction and pressure from ill-fitting or loose shoes causes corns. Corns are seen mainly on or between toes, over bony prominences. The patient should be advised to soak the feet in warm water to soften the corns. The corns should then be gently rubbed with a callus file or pumice stone. Wearing oval corn pads is not advised, because doing so would further increase pressure on the toes and reduce circulation around the toes. Salicylic acid application is recommended for plantar warts. Soaking the feet in an antiseptic solution is advised for ingrown nails.

Which condition is observed in a patient who has gingivitis? 1 Dry mouth 2 Tooth decay 3 Inflammation of the gums 4 Inflammation of sebaceous glands

3 Gingivitis is the inflammation of the gums. Strong sympathetic nervous system stimulation inhibits the release of saliva; this results in xerostomia (dry mouth). Dental caries is tooth decay caused by the interaction of food with bacteria. Acne is an active inflammation of sebaceous glands that causes pimples.

While teaching a patient about denture care, the nurse instructs the patient to avoid wearing dentures while sleeping. What is this instruction intended to prevent? 1 Warping of the dentures 2 Irritation of the gums 3 Stomatitis 4 Gingival infection

3 Instructing the patient to avoid wearing dentures while sleeping will help prevent stomatitis. Keeping dentures covered in water and storing them in an enclosed, labeled cup placed on the patient's bedside stand will help prevent warping. Cleaning dentures on a regular basis will help to prevent irritation and gingival infection.

Which condition may increase the risk of tissue ulceration due to excessive soaking of the feet while providing foot care to a patient? 1 Renal calculi 2 Cirrhosis of the liver 3 Peripheral neuropathy 4 Congestive heart failure

3 Patients who have peripheral neuropathy are at risk of tissue ulceration because soaking causes maceration of tissues. Soaking will not cause the maceration of tissues in patients who have renal calculi, cirrhosis of the liver, and congestive heart failure.

A registered nurse teaches a nursing student about the characteristics of hair. Which statement if made by the nursing student indicates a need for further teaching? 1 "The hair shaft is lifeless." 2 "Hormonal changes affect the hair's characteristics." 3 "Physiological factors directly affect the hair shaft." 4 "Nutrient deficiencies of the hair follicle cause changes in hair color."

3 Physiological factors do not directly affect the hair shaft. The hair shaft itself is lifeless. Hormonal changes, nutrition, and certain illnesses affect the hair's characteristics, and nutrient deficiencies of the hair follicle may change hair color.

Which statement is true regarding the implications of skin care? 1 Constant exposure of the skin to moisture causes chemical irritation. 2 Cosmetics, deodorants, and depilatories cause maceration or softening of the skin. 3 Weakening of the epidermis occurs due to scraping or stripping of the skin's surface. 4 Improper turning or positioning techniques result in the development of pressure ulcers.

3 Scraping or stripping of the skin's surface may be due to a weak epidermis. Constant exposure of the skin to moisture causes maceration or softening of the skin. Cosmetics, deodorants, and depilatories may cause chemical irritation. The loss of stratum corneum results in the development of pressure ulcers. Improper turning or positioning techniques will weaken the epidermis.

A registered nurse teaches a patient about skin protection. Which statement made by the patient indicates the need for further teaching? 1 "I should use emollients." 2 "I should use alkaline soaps." 3 "I should keep my bed linens and clothing wet." 4 "I should minimize the exposure of skin to moisture."

3 The patient's bed linens and clothing should be kept dry to protect the skin. The patient should use emollients to soften the skin and prevent moisture loss. The patient should use alkaline soaps and minimize skin exposure to moisture to prevent ulcer formation.

Which statement is true regarding subcutaneous tissue? 1 Subcutaneous tissue is hostile to bacteria. 2 The oral mucosa is underlined by the thick layer of subcutaneous tissue. 3 The subcutaneous layer contains blood vessels, nerves, lymph, and loose connective tissue. 4 Subcutaneous tissue supports the lower skin layers to withstand stresses and pressure caused by injuries.

3 The subcutaneous tissue layer contains blood vessels, nerves, lymph, and loose connective tissue. Sebum has bactericidal action. The oral mucosa is underlined with a less subcutaneous gland. Subcutaneous tissue supports the upper skin layer to withstand stresses and pressure caused by injuries.

A registered nurse teaches a nursing student about patient-centered care in hygiene practice. Which statements, if made by the nursing student, indicates the need for further learning? Select all that apply. 1 "I should recognize that some cultures prohibit touching." 2 "I should maintain privacy while caring for female patients." 3 "I can uncover the lower torso of women of Middle Eastern or East Asian descent." 4 "I should understand that toileting practices are equal in all cultures." 5 "I can allow the patient's family members to participate in hygiene activities."

3, 4 The nurse should avoid uncovering the lower torso of patients of Middle Eastern and East Asian descent. The nurse should understand that toileting practices differ by culture. The nurse should understand that certain cultures prohibit touching. The nurse should maintain privacy while caring for female patients because some cultures are particular about female modesty. The nurse should allow the patient's family members to participate in hygiene activities to help the patient feel more comfortable.

The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "I have so many pimples on my face, it makes my face look horrible. Can I ever get rid of this problem?" Which instructions should the nurse give to prevent acne? Select all that apply. 1 "Oil your hair frequently." 2 "Use oil-based cosmetics." 3 "Use a good soap to wash your face." 4 "Wash skin and hair thoroughly with warm water." 5 "Avoid applying makeup as much as possible."

3, 4, 5 Acne is an inflammatory condition of the sebaceous glands. Excessive oil makes the skin more prone to develop acne. The skin and hair should be washed regularly with warm water and a good soap to prevent accumulation of dirt or oil in the skin. Makeup containing oil and cream, which may accumulate in the pores of the skin, should be avoided. Excessive oiling of hair and using oil-based cosmetics may lead to acne formation.

The nurse teaches an adult patient about oral hygiene according to American Dental Association guidelines. Which of the patient's statements indicate a need for further teaching? Select all that apply. 1 "I will change my toothbrush every 3 months." 2 "I will use fluoride mouthwash to rinse out my mouth." 3 "I will use lemon-glycerin sponges to clean myoral cavity." 4 "I will use commercially-made foam swabs to brush my teeth." 5 "I will drink the mouthwash directly from the bottle for a mouth rinse."

3, 4, 5 Lemon-glycerin sponges may dry the oral mucosa and lips. These sponges should not be used to clean the oral cavity. Commercially-made foam swabs are ineffective in removing plaque. To prevent cross-contamination, the patient should not drink mouthwash directly from the bottle. Patients should change their toothbrushes every 3 months and use fluoride mouthwash to prevent tooth decay.

What instructions should the nurse give to a patient to ensure effective use of hearing aids? Select all that apply. 1 "You should clean the hearing aid with water." 2 "You may wear hearing aids under heat lamps." 3 "You should replace ear molds every 2 to 3 years." 4 "You should avoid hairspray while wearing hearing aids." 5 "You should initially wear hearing aids for 15 to 20 minutes."

3, 4, 5 The ear molds are generally effective for 2 to 3 years. Therefore, the patient should change the ear molds every 2 to 3 years. Hairspray can get residue on the hearing aid and affect its functioning. Wearing hearing aids for longer periods initially increases discomfort in the patient. Therefore, the patient should initially wear the hearing aids for only 15- to 20-minute periods and gradually increase the length of time. Water damages batteries in hearing aids. Therefore, the patient should clean the hearing aid with a soft cloth. Heat lamps can cause damage to the hearing aid. Therefore, the patient should avoid wearing hearing aids under heat lamps.

The nurse is providing oral hygiene for an unconscious patient. Which actions should the nurse perform? Select all that apply. 1 Use fingers to hold the patient's mouth open. 2 Avoid explaining the steps of mouth care. 3 Seek the assistance of nursing assistive personnel. 4 Use a padded tongue blade to hold the mouth open. 5 Inform the patient when the procedure is completed.

3, 4, 5 When providing oral hygiene to an unconscious patient, the nurse should seek the assistance of nursing assistive personnel. When cleansing the oral cavity, a small oral airway or a padded tongue blade should be used to hold the mouth open; this helps to provide oral care and prevent the patient from biting the nurse's fingers. The patient should be informed when the procedure is completed. The sense of hearing remains intact even in an unconscious patient. Using fingers to hold the patient's mouth open may cause an accidental human bite, which can transmit infection-causing microorganisms. Even though the patient is not awake or alert, the nurse should explain the steps of mouth care and the sensations that the patient will feel.

The registered nurse delegates the skill of shampooing a bedridden patient to a nursing assistive person (NAP). Which actions of the NAP are correct? Select all that apply. 1 Assisting the patient into a sitting position 2 Working up a lather with the dominant hand 3 Starting at the hairline and working toward the back of the neck 4 Massaging the scalp by applying pressure with the fingertips 5 Placing a rolled towel under the patient's neck and a bath towel over the patient's shoulders

3, 4, 5 While shampooing the patient, the nursing assistive person (NAP) should start at the hairline and work toward the back of the neck. The NAP should massage the scalp by applying pressure with the fingertips. The NAP should place a rolled towel under patient's neck and a bath towel over patient's shoulders. The NAP should assist the patient in supine, not sitting, position with head and shoulders at the top edge of bed. The NAP should work up a lather with both hands, not just the dominant hand.

A registered nurse teaches a nursing student about different developmental stages of the skin. Which statements, if made by the nursing student, indicates the need for further learning? Select all that apply. 1 "Toddlers have greater resistance to infections and skin irritation." 2 "Older adults have an increased risk for bruising, dry skin, and itching." 3 "The epidermis and dermis of neonates are tightly bound together." 4 "The growth and maturation of the integument increase during adolescence." 5 "Sweat glands become fully functional when the individual becomes an adult."

3, 5 In neonates, the epidermis and dermis are loosely bound together and the skin is very thin. Sweat glands become fully functional during puberty. A toddler's skin is bound tightly and has greater resistance to infections and skin irritation. An older adult's skin loses resiliency and has very low moisture content; therefore, their skin is mostly dry and is prone to bruising and itching. The growth and maturation of the integument increase during adolescence.

The nurse is preparing the bed of a patient. Which of the nurse's actions are appropriate in this situation? Select all that apply. 1 Placing the soiled linen on the floor 2 Placing soiled linen directly in the hamper 3 Keeping the linen away from the uniform 4 Leaning over the mattress while placing the linen 5 Placing the clean linen in a dirty-linen container if it touches the floor

3, 5 While preparing the bed, the nurse should keep the linen away from the uniform. The nurse should place clean linen in the dirty-linen container if it touches the floor. The nurse should place soiled linen in special linen bags to avoid transmitting infection. The nurse should place the linen in special linen bags before placing it in a hamper. Leaning over the mattress while placing the linen may cause back injuries.

An 82-year-old patient visits the primary health care provider with a complaint of dry feet. Which conditions are responsible for the patient's condition? Select all that apply. 1 Improper fit of footwear 2 Presence of systemic disease 3 Dehydration of epidermal cells 4 Continued exposure to trauma 5 Decrease in sebaceous gland secretions

3, 5 The dehydration of epidermal cells and a decrease in sebaceous gland secretions can lead to dry feet in older adults. Improper fit of footwear can cause discomfort. Systemic diseases can lead to chronic problems. Continued exposure to trauma can lead to abnormalities such as lateral ankles.

During assessment, the nurse finds that a patient with dyspnea is excessively tired. Which actions should the nurse perform to comfort the patient? 1 Notify the registered nurse 2 Obtain a special bed surface 3 Obtain an order for a sitz bath 4 Elevate the head of the patient's bed

4 A patient with dyspnea may be comforted by elevating the head of the bed. A primary health care physician should be notified about the patient's condition if there is a change in the patient's fatigue level. The nurse should obtain a special bed surface for a patient with a risk for skin breakdown to reduce dryness, rashes, and pressure ulcers. A sitz bath is recommended for a patient with an inflamed and swollen rectum, perineum, and genital area.

Which type of bath involves bathing from a bath basin with a patient sitting in a chair? 1 Sitz bath 2 Tub bath 3 Partial bed bath 4 Sponge bath

4 A sponge bath involves bathing from a bath basin with the patient sitting in a chair. A sitz bath is used for a patient with a swollen and inflamed rectum, perineum, and genital area. A tub bath is given to patients in long-term care. A partial bed bath involves washing selected areas of the patient such as the face or perineal area. This type of bath may be done when the patient is in pain or nauseated.

What is the reason for the development of acne in adolescents? 1 Increased skin vascularity 2 Increased thickness of the skin 3 Increased maturation of integument 4 Increased inflammation of sebaceous glands

4 Active inflammation of sebaceous glands leads to the formation of pimples; this condition is called acne. The skin's vascularity increases in adolescents, which causes general skin changes. The skin's thickness increases in boys, along with some darkening in color. During adolescence, the growth and maturation of the integument increases; this growth does not cause acne.

Which instruction provided by the nurse would be most beneficial to a patient who underwent bariatric surgery? 1 "You should keep your bed linens dry." 2 "You should wear smooth linen clothes." 3 "You should maintain proper foot hygiene." 4 "You should use adaptive bathing methods."

4 Adaptive bathing methods are beneficial for patients who undergo bariatric surgery. Keeping the bed linen dry can help protect the skin. Wearing smooth linen clothes can minimize friction. Proper foot hygiene is important for patients who have diabetes.

The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "For the past few weeks, I have been perspiring a lot, especially in the underarm area. What should I do?" Which is the most appropriate response by the nurse? 1 "Please consult a health care provider for this." 2 "Sweating is filthy. Please use talcum powder." 3 "You need to have antibiotics for this." 4 "This is just a normal part of growing up."

4 Adolescents tend to sweat more as they reach puberty due to the fact that the sweat glands become very active during this phase. The nurse should explain to the student that this is not an abnormal phenomenon. The student need not consult a doctor or use antibiotics for excessive sweating. The nurse should always understand the patient's problems and be empathetic; saying that sweating is filthy could hurt the student's feelings.

A patient is diagnosed with pediculosis corporis, or body lice, and is given pediculicide lotion for it. The nurse instructs the patient to apply the lotion after bathing when the skin is wet. A second bath should be taken 12 to 24 hours after the first one, and the infested clothing should be washed in hot water. The patient is also instructed to vacuum the rooms thoroughly and throw away the vacuum bags. Which instruction may lead to worsening of pediculosis? 1 Washing the infested clothing in hot water. 2 Taking a second bath 12 to 24 hours after the first one. 3 Vacuuming rooms thoroughly and throwing away the bags. 4 Applying pediculicide lotion after bathing when the skin is wet

4 For treatment of body lice, the patient should be instructed to take a thorough bath and apply pediculicide lotion when the skin is dry. Wet skin contains moisture, which can promote the growth of lice. The patient should take a second bath 12 to 24 hours after the first one and apply a second dose of the lotion. The infested clothing or linen should be washed in hot water to remove the lice. Rooms should be vacuumed thoroughly and the vacuum bags should be thrown away to prevent reinfestation.

A registered nurse teaches a nursing student about the implications of skin care. Which statement if made by the nursing student indicates a need for further learning? 1 "I should smooth the bed linen out regularly." 2 "I should remove rings from the patient's fingers." 3 "I should check that the patient's bath water is not excessively hot or cold." 4 "I should maximize friction by moving the patient frequently."

4 Friction should be minimized to reduce the risk of pressure ulcers. Smoothing the bed linen out helps remove sources of mechanical irritation. The nurse should remove rings from the patient's fingers to prevent accidental skin injuries. The nurse should make sure that the patient's bath water is not excessively hot or cold to prevent skin injuries.

The nurse in a nursing home finds that all the patients who are in long-term care have head lice and a few of them have ticks. They are given appropriate treatment and instructions. Which infection is caused by the lice? 1 Tularemia 2 Lyme disease 3 Rocky Mountain spotted fever 4 No infection

4 Head lice do not cause infection by themselves. The infections Tularemia, Lyme disease, and Rocky Mountain spotted fever are transmitted by ticks, which are small, gray-brown parasites that burrow into the skin.

The nurse is teaching oral hygiene to a patient to prevent infection. Which of the patient's statements indicates a need for further teaching? 1 "I will use a battery-powered toothbrush." 2 "I will change my toothbrush every 3 months." 3 "I will use a small brush to reach all areas of the mouth." 4 "I will use lemon-glycerin sponges to clean my mouth."

4 Lemon-glycerin sponges dry mucous membranes and erode tooth enamel, so they should not be used; this statement indicates a need for further teaching. The remaining statements indicate effective learning: A battery-powered or electric toothbrush improves the quality of cleaning. A toothbrush should be replaced every 3 months to minimize the growth of microorganisms on the brush surfaces. Toothbrushes should be small and straight handled to reach all areas of the mouth.

Which patient is considered least in need of perineal care? 1 A patient who underwent rectal surgery 2 A patient with indwelling urinary catheter 3 A patient who gave birth to a child recently 4 A patient who underwent penile circumcision two years prior

4 Male patients who underwent penile circumcision are at a decreased risk of developing an infection. Therefore, these patients are least likely to require perineal care.

What is a common foot problem that affects middle-aged women? 1 Corns 2 Calluses 3 Fungal infections 4 Morton's neuroma

4 Morton's neuroma is a common condition that affects middle-aged women; this condition causes burning, numbness, and foot pain. Corns, calluses, and fungal infections are common in older adults.

How might a nurse instruct a patient with pediculosis capitis? 1 Avoid using hair picks 2 Avoid using hair curlers 3 Avoid using a tongue depressor 4 Avoid using products containing lindane

4 Pediculosis capitis is head lice infestation, caused by parasites that reside on the scalp and attach to hair strands. Special shampoos are available to treat lice, but products containing lindane should be avoided, because it can cause toxic reactions. Hair picks and hair curlers should be avoided for alopecia, not head lice, because they may cause hair loss, but these should not be shared with others in order to prevent the spread of lice. A tongue depressor is fine to use for checking the entire scalp.

The nurse advises a patient to avoid the use of dry razors. Which condition is the nurse trying to prevent? 1 Chemical irritation 2 Mechanical irritation 3 Loss of stratum corneum 4 Weakening of the epidermis

4 The use of dry razors can scrape or strip the skin's surface. Weakening of the epidermis occurs by scraping or stripping the skin's surface. Chemical irritation may occur due to the misuse of soap, detergents, cosmetics, deodorant, and depilatories. Mechanical irritation may occur when smooth fiber cloths are not used. Loss of stratum corneum may occur due to friction.

A nurse provides oral care to a patient. Which nursing intervention is contraindicated if there is an accumulation of oral secretions? 1 Turning the patient's head to the side 2 Notifying the primary health care provider immediately 3 Elevating the head of the bed after clearing the secretions 4 Using the catheter for both oral and tracheal cavities

4 To suction secretions, a separate catheter should be used for oral and tracheal use. The patient should be turned onto one side to prevent complications. The nurse should immediately notify the primary health care provider if the patient aspirates. The nurse should elevate the head of the bed after clearing oral secretions to promote breathing

The registered nurse is evaluating a nursing student who is assisting a bedridden patient in shaving with a razor. Which action of the nursing student demonstrates a need for further learning? 1 Checking the razor for clean blade 2 Moistening the skin with lukewarm water 3 Using long, firm razor strokes in the direction the hair grows 4 Using short, upward strokes to remove hair on the chin

4 While removing hair over the upper lip or chin, the nurse should use short, downward, not upward, strokes to most efficiently remove this hair. The other actions indicate adequate understanding. The razor should be checked for a clean blade before use. The skin should be moistened with lukewarm water. Long, firm razor strokes should be used in the direction the hair grows.

A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: A. It promotes venous circulation. B. It covers a larger area of the leg. C. It completes care in a timely fashion. D. It prevents blood clots in legs.

A Bathing a patient with long, firm strokes distal to proximal promotes circulation and increases venous return.

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? A. Use tap water to clean soft lenses. B. Follow recommendations of lens manufacturer when inserting the lenses. C. Keep lenses moist or wet when not worn. D. Use fresh solution daily when storing and disinfecting lenses.

A The patient should not use water to clean soft contact lenses.

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. What is the correct order for administration of oral care? 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex. A. 2, 5, 1, 3, 6, 4 B. 5, 1, 2, 3, 6, 4 C. 2, 5, 3, 1, 6, 4 D. 2, 1, 5, 3, 4, 6

A This is the correct order for administration of oral care.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) A. Use antimicrobial toothpaste. B. Brush teeth 4 times a day. C. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. D. Use a soft toothbrush for oral care. E. Avoid cleaning the gums and tongue.

A, C, D The American Dental Association guidelines (2014) for effective oral hygiene include brushing the teeth at least twice a day with an American Dental Association approved fluoride toothpaste. Use antimicrobial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor oral hygiene (e.g., older adults and patients with cognitive impairments and who are immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Patients should clean gum and the surface of the tongue.

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) A. Dentures do not always fit properly. B. Most older adults have an increase in saliva secretions. C. With aging the periodontal membrane becomes tighter and painful. D. Many older adults are edentulous, and remaining teeth are often decayed. E. The teeth of elderly patients are more sensitive to hot and cold.

A, D Dentures or partial plates do not always fit properly, causing pain and discomfort. Many older adults are edentulous (without teeth), and the teeth that are present are often diseased or decayed. An age-related decline in saliva secretion is common. The periodontal membrane weakens with aging, making the area prone to infection. Normally aging does not affect temperature sensitivity.

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nurse assistant to accomplish during the bath? A. Checking distal pulses B. Providing range-of-motion (ROM) exercises to extremities C. Determining type of treatment for stage 1 pressure ulcer D. Changing the dressing over an intravenous site

B ROM may be delegated to assistive personnel. The other activities should be performed by the nurse.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) A. Prone position B. Sims position C. Semi-fowler's position with head to side D. Trendelenburg position E. Supine position

B, C Place the unconscious patient in semi-Fowler's position with head to the side or use the Sim's position to help avoid aspiration while performing oral care. The supine and Trendelenburg positions would make it easier for a patient to aspirate. The prone position would not be suitable for accessing the oral cavity.

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) A. Cut nails frequently. B. Assess skin for redness, abrasions, and open areas daily. C. Soak feet in water at least 10 minutes before nail care. D. Apply lotion to feet daily. E. Clean between toes after bathing.

B, D, E Because of a patient's risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes because this may create skin breakdown and open sores, leading to skin breakdown or infection.

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from a diagnostic test B. A patient who prefers a bath in the evening when his wife visits and can help him C. A patient who is experiencing frequent incontinent diarrheal stools and urine D. A patient who has been awake all night because of pain 8/10

C A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling, whereas patients who are normally inactive during the day and have skin that tends to be dry may need to bathe only twice a week.

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: A. Obsessive compulsive behavior. B. Personal preferences. C. The patient's cultural norm. D. Controlling behaviors.

C Cultural beliefs often influence patients' hygiene practices. Middle Eastern practices encourage one hand to be kept clean at all times.

A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: A. Community mouthwash. B. Alcohol-based mouth rinse. C. Normal saline rinses. D. Firm toothbrush.

C Normal saline is the safest solution to use in caring for a patient with stomatitis. Alcohol and community mouthwashes can be irritating and burning. A soft toothbrush should be used.

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.) A. Oxygen saturation B. Heart rate C. Respirations D. Gag reflex E. Response to painful stimulus

C, D Check a patient's respirations and whether there is a gag reflex present to determine risk for aspiration and to establish a baseline for the patient's condition.

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) A. Use of cough drops B. Immunosuppression C. Radiation therapy D. Dehydration E. Presence of oral airway

C, D Radiation therapy reduces salivary flow. Dehydration impairs salivary secretion in the mouth. Cough drops increase sugar or acid content in the mouth, causing caries. Immunosuppression causes inflammation and bleeding of the gums. An oral airway irritates oral mucosa.

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? A. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period. B. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line. C. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. D. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.

D All of the patients require careful bathing. The 44-year-old female needs good perineal hygiene. The 56-year-old patient is at risk for drying and fragility of the skin. The 60-year-old patient has reduced sensation and mobility and thus is unaware of skin problems or pressure areas. However, the 70-year-old patient has reduced circulation, which increases risk for infection, and is likely unaware of skin problems because of dementia. The presence of stool will also irritate the skin.

When a nurse delegates hygiene care for a male patient to a nurse assistant, the assistant to must use an electric razor to shave the patient with the following diagnosis: A. Congestive heart failure B. Pneumonia C. Arthritis D. Thrombocytopenia

D Patients prone to bleeding (e.g., those receiving anticoagulants or high doses of aspirin or those with low platelet counts) need to use an electric razor.