Davis Edge - Hygiene

Which term describes a type of bath in which a client is in bed but able to bathe himself or herself? 1. Bed bath 2. Tub bath 3. Therapeutic bath 4. Bag bath

1. Bed bath

A new client on the medical-surgical unit has not bathed in several days although she is fully capable of engaging in personal hygiene practices and ADLs. Upon investigation, the nurse learns she is homeless and typically utilizes the services of the homeless shelter once a week for her bathing and other hygiene needs. What is an appropriate nursing outcome for this client? 1. Client demonstrates lifestyle changes to meet self-care needs. 2. Client identifies useful resources in optimizing autonomy and independence. 3. Client safely executes self-care activities to utmost capability. 4. Client recognizes individual weakness or needs.

1. Client demonstrates lifestyle changes to meet self-care needs.

When assessing a client for self-care abilities, what observations should be addressed? Select All That Apply. 1. Complete independence 2. Requires a device or special equipment 3. Requires help, supervision, or teaching from another person 4. Is totally dependent 5. If the walking space is uncluttered

1. Complete independence 2. Requires a device or special equipment 3. Requires help, supervision, or teaching from another person 4. Is totally dependent

Which factors can affect a person's hygiene practices? Select All That Apply. 1. Culture 2. Developmental level 3. Career choice 4. Tolerance for cold 5. Economic status

1. Culture 4. Tolerance for cold 5. Economic status

What skin conditions should be monitored for in a client with Risk for Impaired Skin Integrity? Select All That Apply. 1. Dampness 2. Dehydration 3. Inadequate circulation 4. Nutritional status 5. Wound healing

1. Dampness 2. Dehydration 3. Inadequate circulation 4. Nutritional status

A 68-year-old Orthodox Jewish man was admitted last week after a massive heart attack. Although his eyes are open, he does not respond to external stimuli. Because of impaired swallowing, Mr. Gold is unable to take food or fluid orally. A feeding tube was placed to ensure adequate nutrition and hydration. His oral mucous membranes and lips are dry and crusty. He is incontinent of urine and stool. Mr. Gold's son, Ira, tells you that Mr. Gold adheres to Orthodox Jewish law and requests that you respect this in his care. How should the nurse handle his bathing and other personal hygiene needs? 1. Delegate personal hygiene assistance to a male NAP. 2. Ask a family member to assist the client with his hygiene needs. 3. Protect the modesty of the client as much as possible, but proceed as normal. 4. Encourage the client to perform personal hygiene as best as possible.

1. Delegate personal hygiene assistance to a male NAP.

What would be an appropriate outcome for a nursing diagnosis of Impaired Walking r/t foot pain secondary to arthritis? 1. Demonstrates measures to increase mobility 2. Wears shoes that fit properly 3. Inspects feet regularly 4. Uses safety measures to minimize potential for injury

1. Demonstrates measures to increase mobility

What is important to remember when conducting perineal care for a client? 1. Drape the client appropriately to protect modesty. 2. A nurse/NAP of the same gender should conduct perineal care. 3. Clients should be facing the opposite direction to avoid embarrassment. 4. A family member must be present to ensure client comfort.

1. Drape the client appropriately to protect modesty.

An 84-year-old was admitted with a medical diagnosis of Malignant Hypertension and Pneumonia and needs assistance with self-care, including oral hygiene. Why is it important for the nurse to fully inspect and assess the oral cavity while assisting with oral hygiene in this client? 1. Due to increased risk of systemic infection 2. To monitor for developing carcinomas 3. To let the client demonstrate correct technique for brushing and flossing 4. To monitor for excess sugar levels of in-between meal snacks

1. Due to increased risk of systemic infection

1. Inspect nails daily. 2. Clip toenails straight across. 3. If cuticles are rough, the client should bite them until they are flush with the skin. 4. Sharp nail scissors should be used for cutting toenails. 5. Use moisturizing lotion to soften cuticles

1. Inspect nails daily. 2. Clip toenails straight across. 5. Use moisturizing lotion to soften cuticles

When educating a client on nail care of the feet, what important aspects should be included? Select All That Apply. 1. Inspect nails daily. 2. Trim with clippers, or file if diabetic. 3. File nails straight across slightly rounding edges. 4. Cut cuticles back with a cuticle clipper. 5. Remove ingrown nails with a cuticle clipper.

1. Inspect nails daily. 2. Trim with clippers, or file if diabetic. 3. File nails straight across slightly rounding edges.

What eye care interventions should a nurse make for a comatose client? Select All That Apply. 1. Keep eyes lubricated every 2 to 4 hours with saline. 2. Use a protective eye shield to keep eyes closed. 3. Instill eye ointment on lower lids as prescribed. 4. Use warm water to cleanse the eye area every 2 to 4 hours. 5. Eyes appear clean and without redness or drainage.

1. Keep eyes lubricated every 2 to 4 hours with saline. 2. Use a protective eye shield to keep eyes closed. 3. Instill eye ointment on lower lids as prescribed.

A nurse is assigned a client who is temporarily non-ambulatory and with a nursing diagnoses including Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. What information should be provided when delegating assistance? Select All That Apply. 1. Limitations and restrictions 2. Specific safety precautions 3. Presence of obstacles 4. Observations to make during the procedure and why they are important. 5. Scheduled care time and length of time needed

1. Limitations and restrictions 2. Specific safety precautions 3. Presence of obstacles 4. Observations to make during the procedure and why they are important.

A student nurse is bathing an obese client for the first time. What intervention could be suggested for bathing this client? Select All That Apply. 1. Offer a handheld shower with a long-handled brush. 2. Apply moisture barrier creams after bathing. 3. Separate skin folds with towels. 4. Rinse and dry the skin well. 5. Use breathable materials including bed linens.

1. Offer a handheld shower with a long-handled brush. 2. Apply moisture barrier creams after bathing. 3. Separate skin folds with towels. 4. Rinse and dry the skin well. Breathable linens should be used but this is not a part of the bathing process >:(

When assessing pallor in a light-skinned client, how does the skin appear? 1. Pale without underlying tones of pink 2. Ashen gray or yellow in appearance 3. Redness, often in patches 4. Slight bluish color

1. Pale without underlying tones of pink

What would be an appropriate intervention for a client with a nursing diagnosis of Risk for Impaired Skin Integrity related to changes in skin barrier function? 1. Protect the client's healthy skin from the possibility of maceration by using appropriate hydrofiber or alginate dressings. 2. Monitor vital signs, capillary refill, and the status of the mucous membranes. 3. Elevate affected extremities whenever possible. 4. Perform actions to maintain an adequate nutritional status.

1. Protect the client's healthy skin from the possibility of maceration by using appropriate hydrofiber or alginate dressings.

A 34-year-old client who is 28 weeks' pregnant complains of bleeding gums during her obstetrics examination. What can this be attributed to? 1. Rise in estrogen levels 2. Vitamin deficiency 3. Excess folic acid 4. Depletion of iron in the blood

1. Rise in estrogen levels Increased estrogen results in increased vascularity of the gingiva

A new client on the medical-surgical unit has not bathed in several days although she is fully capable of engaging in personal hygiene practices and ADLs. Upon investigation, the nurse learns she is homeless and typically utilizes the services of the homeless shelter once a week for her bathing and other hygiene needs. What is an appropriate nursing diagnosis for this client? 1. Self-care deficit 2. Ineffective hygiene maintenance 3. Disturbed body image 4. Unilateral neglect

1. Self-care deficit

What must the nurse consider in regards to the integrity of the aging adult's skin? Select All That Apply. 1. Skin is thinner and more fragile. 2. Glandular activity decreases. 3. Collagen and elastin fibers weaken and become less elastic. 4. Skin is susceptible to bacterial infections such as MRSA. 5. Keratin production causes skin to become tough in areas.

1. Skin is thinner and more fragile. 2. Glandular activity decreases. 3. Collagen and elastin fibers weaken and become less elastic.

What benefits can the client experience from bathing? Select All That Apply. 1. Stimulates depth of respirations and provides sensory input. 2. The warmth and friction dilate blood vessels near the surface of the skin, increasing the circulation. 3. It can be a time to strengthen the nurse-client relationship. 4. It promotes relaxation and comfort, enhances well-being, and improves self-image. 5. The approach, method, and time can be adapted to suit the client.

1. Stimulates depth of respirations and provides sensory input. 2. The warmth and friction dilate blood vessels near the surface of the skin, increasing the circulation. 3. It can be a time to strengthen the nurse-client relationship. 4. It promotes relaxation and comfort, enhances well-being, and improves self-image While the approach, method, and time can be adapted, this is more a convenience for nursing staff than a benefit to the client.

A 70-year-old client has a nursing diagnosis of Self-Care Deficit: Dressing r/t decreased strength and endurance and loss of muscle control and coordination. What is an appropriate nursing intervention for the client? 1. Use Velcro fasteners instead of buttons and zippers. 2. Push the client to reach goals of self-care. 3. Provide self-help devices: extensions with hoods for picking things up from the floor. 4. Create a plan for visual deficits that are present: Place clothing on bed.

1. Use Velcro fasteners instead of buttons and zippers.

A nurse is performing oral care on an unconscious client. How should the nurse hold the mouth open? 1. Use a padded tongue blade. 2. Use fingers to open the mouth. 3. Use a toothbrush to open the mouth. 4. Use gauze to hold the teeth.

1. Use a padded tongue blade.

When addressing the needs of a nonambulatory client with severe Vitamin D deficiency, what might be an appropriate intervention? 1. Use of ultraviolet light in the room 2. Have client spend time outside 3. Administer multivitamin as prescribed 4. Monitor for skin integrity

1. Use of ultraviolet light in the room

hich are Centers for Disease Control recommendations for use of water in caring for contact lenses? Select All That Apply. 1. Contact lenses should be washed daily with soap and water. 2. Contact lenses should be removed before showering or swimming. 3. Water can cause soft lenses to swell and stick to the eye. 4. Users should store lenses in water. 5. If water touches the lens, the user should discard them.

2. Contact lenses should be removed before showering or swimming. 3. Water can cause soft lenses to swell and stick to the eye. 5. If water touches the lens, the user should discard them.

A nurse is assisting a client who has had a stroke that caused the loss of use of the left side with activities of daily living. What actions can the nurse take to encourage self-care and as much independence as possible? 1. Instruct the client to allow the nurse to help with bathing, as the client cannot do this activity alone. 2. Place all hygiene items on the client's right side and assist with what the client cannot reach. 3. Instruct the client to do as much as possible and not to worry about the rest. 4. Place all hygiene items on the left side to encourage the client to use that side.

2. Place all hygiene items on the client's right side and assist with what the client cannot reach.

An elderly client is ambulatory but requires assistance with bathing. The client has episodes of incontinence and his or her bed and gown is soiled. Which type of bath would be most appropriate? 1. Complete bath 2. Tub bath 3. Partial bath 4. Towel bath

2. Tub bath Tub bath is appropriate since the client is ambulatory and this will provide the best cleaning.

The nurse is assigned a 39-year-old client who is temporarily nonambulatory due to a car accident that resulted in a fractured pelvis and femur. One nursing diagnosis is Self-Care Deficit: Bathing. Using the NOC ranking system for self-care, which category would this client fall into? 1. (1) dependent, does not participate 2. (2) requires assistive person and device 3. (3) requires assistive person 4. (4) independent with assistive device 5. (5) completely independent

3. (3) requires assistive person

A nurse has washed a postsurgical client's back and perineal area because these are the areas the client could not reach. What is the term for this bath? 1. Complete bath 2. Partial bath 3. Assist bath 4. Bed bath

3. Assist bath Complete bath is done when a client cannot assist at all. Partial bath is bathing areas that may cause odor or are susceptible to bacterial growth, including the perineal area and axillae. Clients who must remain in bed but who are able to bathe themselves can complete a bed bath.

A client has a high risk of gum bleeding due to painful mouth lesions. What might the nurse consider as a precaution? 1. Brush teeth very quickly to avoid bleeding. 2. Instruct the client to brush his or her teeth and be prepared with gauze. 3. Brush teeth with a foam or cotton mouth swab. 4. Avoid brushing teeth and only use mouth rinse

3. Brush teeth with a foam or cotton mouth swab.

When washing a client's legs, which direction is correct? 1. Proximal to distal 2. Short, circular motions 3. Distal to proximal 4. Gently patting the limb

3. Distal to proximal Promotes venous return

Which is the most appropriate nursing diagnosis for a client who has trimmed his or her nails incorrectly and has developed ingrown toenails? 1. Risk for injury related to infection from ingrown toenails 2. Risk for infection related to improper nail trimming technique 3. Risk for impaired skin integrity related to ingrown nails from improper trimming 4. Impaired mobility related to toe pain caused by ingrown toenails

3. Risk for impaired skin integrity related to ingrown nails from improper trimming

Which is the most preferred method of bathing for ambulatory clients? 1. Tub bath 2. Partial bath 3. Shower 4. Complete bath

3. Shower

Which type of bath is most likely to be a medical order? 1. Bed bath 2. Tub bath 3. Therapeutic bath 4. Assist bath

3. Therapeutic bath

A client is providing A.M. care to a client who is on anticoagulation therapy. When assisting the client with shaving, which consideration should be taken? 1. Shave with a straight razor in an up-and-down motion. 2. Use a one-time only razor, then dispose. 3. Use an electric razor. 4. Use surgical clippers.

3. Use an electric razor.

A nurse provides a bath in which the nurse washes the client's entire body. The client is unable to assist. Which type of bath is this? 1. Partial bath 2. Assist bath 3. Therapeutic bath 4. Complete bath

4. Complete bath

When is a back massage typically offered as part of scheduled care? 1. Morning care 2. Early morning care 3. Afternoon care 4. H.S. care

4. H.S. care H.S. = hour of sleep

The nurse is assigned a 39-year-old client with the nursing diagnoses Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. When would be the most appropriate scheduled care time to address the bathing needs of this client? 1. Hourly rounds 2. PM care 3. Early morning care 4. Morning care

4. Morning care This is a part of the typical hospital schedule.

When conducting a basin and water bath, in what order is the client washed?

Eyes Chest Abdomen Legs and feet Back and buttocks Rectum and perineal area