Fundamentals of Nursing CH 17: Hygiene/e
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."
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?
"I will use conditioner so that the lice eggs will slide off my hair."
The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?
"Let me assess the patches. They may indicate the development of a fungal infection."v
The nurse is caring for a client who states, "I never remove my contact lenses." What is the appropriate nursing response?
"Let's talk about how to clean your contacts."
A client who has been reluctant to have their hair shampooed for a week tells the nurse, "I don't want you to shampoo my hair. It doesn't need washing." The client's hair is very greasy, the scalp is irritated, and it has begun to smell. What is the appropriate nursing response?
"Let's talk about what might be bothering you about your hair."
The client questions the nurse about the best manner to clean the ears. What should be included in the information provided to the client?
Use the twisted end of a clean washcloth and pull auricle down.
An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin?
activity of the glands in the skin lessens
A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:
alopecia.
The nurse is reviewing the medication history for a newly admitted client. The nurse correctly recognizes that xerostomia may be noted with:
antihistamine use.
A nurse is caring for a client who is receiving care for a traumatic head injury that has rendered the client unconscious. When providing mouth care for this client, the nurse must be cognizant of the client's risk for:
aspiration.
When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:
assessment of tissues.
Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition?
caries
During a regular dental checkup the client expresses concern to the nurse regarding discoloration of the teeth. Consumption of what food would be the most likely reason for the discoloration of the client's teeth?
coffee
A nurse is assessing the skin of an older client with dry skin and notices several areas of scratches and abrasion. Interventions should be implemented to:
decrease the risk of infection.
A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair:
facilitates oil distribution.
When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:
hair should be washed as often as necessary.
When the nurse cleanses the client's leg during a bed bath, it will allow for:
increased circulation.
A client is admitted to the health care facility with a diagnosis of pediculosis capitis. What would the nurse expect to find in the client?
inflamed bites along the hairline
The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client's to avoid that is on the dietary tray?
jelly to go on the toast
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)
A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care?
middle-age woman with a Foley catheter
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
The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?
partial care
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:
pediculosis.
The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?
pulling the razor against the direction of hair growth
A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving, what would be most important?
shaving in the direction of hair growth
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 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?
sitz bath
A client who has been admitted in the health care facility has had surgery and is unconscious. The nurse needs to take care of the client's hygiene and oral care daily. The client's teeth and lips show dry crusts when there is a day's gap in the oral hygiene. What can best describe the client's oral condition?
sordes
A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made?
the head for nits on hair shafts
A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:
there is a need to determine if the bottled water has fluoride.
Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water?
to prevent drying and warping of plastic
A 76-year-old client is admitted to the health agency with a stroke. The nurse, while bathing the client, starts wiping and cleaning the body from feet onward. The client is incapable of assisting the nurse in the bathing process. Which technique is the nurse using to bathe the client?
towel bath
The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?
traditional bed bath with linen change
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?
underneath the breasts and in between skin folds
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:
understand that his culture may influence his hygiene and ask him his preference.
A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse?
using ungloved hands to remove an unconscious client's dentures
A nurse at a long-term care facility is planning to trim the toenails of many residents, most of whom are unable to do this hygiene task independently. The nurse should consult with a podiatrist before cutting the toe nails of a resident:
who has a history of type 1 diabetes.
A sitz bath would be most appropriate for which client?
33-year old who is one day postpartum
A nurse is reviewing proper toothbrushing procedures with a family. At what angle would the nurse advise to hold a manual toothbrush when cleaning the teeth? Record your answer using a whole number.
45
A nurse is assisting a client to shave his beard. Which statement accurately describes a recommended step in this process?
Apply cream to area to be shaved in a layer about ½-inch thick.
A nurse is caring for a female client with diarrhea. What instruction should the nurse give the client with regard to perineal hygiene?
Clean the perineal area from the front to back.
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.
A nurse is providing oral care to a client with dentures. What action would the nurse perform first?
Don gloves.
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.
What is a correct guideline to follow when providing a bed bath for a client?
Fold the washcloth like a mitt on your hand so that there are no loose ends
What is a correct guideline to follow when providing a bed bath for a client?
Fold the washcloth like a mitt on your hand so that there are no loose ends.
According to common practice, when are the bed linens usually changed?
Following the bath
A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record?
Gingivitis
Which client would be at greatest risk for injury to the skin and mucous membranes?
Man 77 years of age with diabetes
The nurse manager is preparing to educate newly hired nurses about fingernail hygiene. Which education is appropriate?
No nail treatments can be utilized. Clean under the fingernails when washing hands.
What type of bath is preferred to decrease the inflammation after rectal surgery?
Sitz bath
Clients should be allowed to complete as much of a bath as they can.
True
An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?
Use a nonsoap cleaning agent.
A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. What technique would the nurse employ when providing foot care?
Use an antifungal powder on the client's feet, if necessary.
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?
Use electric razor for shaving purposes.
When providing oral care, what does the nurse recognize as the most important component of the oral care process?
a thorough, mechanical cleaning
On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to
assess the client's safety.
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)?
back massage
A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. Which condition may result from chemotherapy?
loss of hair
The nurse is caring for a client with tinea cruris. What assessment findings does the nurse anticipate finding?
sore, itchy cluster of scaly, cracked vesicles
A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth?
trom the pubic area toward the anal area
The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?
"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."
A nurse educates a student nurse in a long-term care facility on recommended skin care practices for older adult clients. Which statement made by student indicates that further education is required regarding this practice?
"I will check the client's skin on a weekly basis."
The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction?
"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."
A parent reports that their home water is not fluoridated and questions the nurse whether it would be benefitial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?
"In the absence of fluoridated water supplies, supplementation is often recommended."
The nurse is caring for an older adult client in a long term care facility that is incontinent of urine. The client is very upset about this loss of dignity and expressing anger to the nurse providing care. He states, "Get away from me. I can get to the restroom on my own. You don't know what I need." Which response would be the most therapeutic for the nurse to say?
"It sounds as if you are angry. Let's talk about it"
The acute care nurse is talking with an older client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?
"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact."
A client expresses concern regarding the use of a bag bath. Which statement by the nurse is most appropriate? (Select all that apply.)
"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." "The bag bath will reduce the spread of bacteria since we are able to use separate cloths." "Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?
"These brown spots are senile lentigines and are common when you get older."
A nurse is caring for a client with long hair. The client asks if something could be done about her hair to be more comfortable. How would the nurse respond?
"Yes, I can braid it for you if you want me to."
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."
Which client is most at risk for foot difficulties?
45-year-old woman with type 2 diabetes
The nurse is caring for four clients. For which client is a sitz bath most appropriate?
51-year old with hemorrhoids
The nurse is assisting with morning care for a group of clients. For which clients is a safety razor contraindicated? (Select all that apply.)
68-year old taking anticoagulants for deep venous thrombosis 45-year old with liver disease and impaired clotting 26-year old who is suicidal and requests to shave 30-year old with inflammation of facial skin
A nurse on an acute medical unit is responsible for providing assistance with hygiene for clients who are unable to do so independently. The nurse should be aware that the use of a safety razor for shaving is contraindicated from which client?
A man who is receiving an intravenous infusion of an anticoagulant for the treatment of a pulmonary embolism
A client is unable tto remove their contact lenses after being involved in a motor vehicle crash. What nursing actions can be used to remove the client's soft contact lenses? (Select all that apply.)
Ask the client remove them, if able. Use the pads of the index finger and thumb to gentle pinch and remove the lens.
A nurse is teaching self-care measures to a client diagnosed with scabies. Which instruction is accurate? (Select all that apply.)
Bathe thoroughly in the morning and at night. Apply prescribed medication after bathing. Don clean clothes after bathing. Avoid skin-to-skin contact with uninfected people.
A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply.
Bathing removes organisms from the skin, reducing infection. Bathing can stimulate circulation. Bathing can improve appearance and self-image.
Which is a recommended guideline when removing contact lenses from a client's eyes?
Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea.
The nurse is preparing to provide hygiene for a client with obesity who has bedrest ordered for 3 days. What is the priority nursing intervention that will be performed to deliver hygiene care?
Check order within the plan of care for hygiene.
A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate? (Select all that apply.)
Contact healthcare provider regarding diminished pedal pulses. Contact a podiatrist.
The nursing is prepraring to provide hygiene to a middle-aged male client who practices Christianity. The client told the nurse that he had his bath yesterday and does not need a bath today. What factors may be the reasons the client declined the bath? Select all that apply.
Culture Health status Personal preferences
Self-care refers to a person's ability to perform primary care functions- in four areas- without the help of others. Which is not one of these areas?
Driving
The nurse is planning hygiene care for a client with self care bathing deficit related to weakness. Which nursing intervention is appropriate?
Encourage the client to wash own face and hands.
A nurse is caring for a client with hemorrhoids. The physician has ordered sitz baths for the client twice a day. What would the nurse do when giving a sitz bath?
Ensure that the pelvic region is immersed in the water.
The nurse is discussing hygiene with a client. The client states that not understanding the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply.
Excessive perspiration will result in potentially offensive odor. Bacteria can flourish in the presence of excessive perspiration. Perspiration promotes skin breakdown.
Bathing should be performed in an orderly, head-to-toe manner.
False
Older, continent clients who are hospitalized should receive a full bed bath with soap and water every day.
False
When shaving a male client's face, pull the skin taut and use short, upward strokes
False
When shaving a male client's face, pull the skin taut and use short, upward strokes.
False
In order to maintain a healthy and hygienic integumentary system, a nurse is clipping the overgrown nails of an older adult client. Which other part should the nurse check to maintain the hygiene of the client's integumentary system?
Hair
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.
A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment?
Lindane
A nurse is going to bathe a client who is confined to bed. What does the nurse do first?
Perform hand hygiene.
Which health problem is most clearly suggestive of a history of inadequate dental care?
Periodontitis
While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate?
Periodontitis
A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply.
Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position.
A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do?
Provide supplies and assist with hard-to-reach areas.
Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agents. What is an appropriate consideration when assisting the client with morning hygiene?
Provide the client with an electric shaver.
A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include?
R/t right-sided weakness
A nurse is assisting a client with a sitz bath. For what reasons is a sitz bath used? (Select all that apply.)
Removes blood, serum, stool, or urine Reduces local swelling Relieves discomfort
The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which methods for warming the premoistened cloths is correct?
Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.
The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?
Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.
A home care nurse visits a client for follow up. During the visit, the client asks the nurse to explain the process for cleaning the soft contact lenses that he recently acquired. Which instruction would the nurse include when educating the client about contact lens care?
Rinse with cleaning solution to remove debris.
A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for this procedure?
Shave with the direction of hair growth in downward, short strokes.
A nurse is preparing to provide oral care to a client who is unconscious. The nurse would place the client in which position?
Side-lying
An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures?
Store the client's dentures in water when the client is not wearing them.
The nurse is teaching a client about hearing aid care. Which teaching is appropriate?
Store the hearing aid in cool environment.
The nurse is caring for a client who voices concerns about the development of her 8-month-old daughter. Which finding would be a source of concern?
The child is unable to hold a spoon to attempt self-feeding.
A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?
The client should be placed in a side-lying position to prevent aspiration.
A client reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which of the following? Select all that apply.
Thermal extremes Poor oral hygiene Adverse reaction to medications Bacteria
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.
A nurse is educating an adolescent regarding care of acne that is present on the face and neck. What actions should the nurse educate the client about that will promote healing and prevent outbreaks?
Use oil-free, water-based moisturizers and makeup.
The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care?
Use small amounts of water and oral suction device.