PrepU Chapter 31

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

51-year old with hemorrhoids

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

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

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

"I will set up your bath for you. I will come back and help you with your bath."

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

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

Use special perineal skin cleaners and moisture barriers.

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."

The health care environment can be very stressful for a client. During an orientation session of nursing students, the nursing instructor teaches students how to minimize a stressful environment. Which statement from the students indicates the teaching was effective? Select all that apply.

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

When performing health education regarding hygiene, the nurse should advise female clients to avoid the use of which products/activities? Select all that apply.

-Routine douching -Vaginal deodorants

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.

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?

Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.

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

Contact a podiatrist to care for toenails.

A client age 78 years needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation?

Gently slide the hard lens over the cornea and remove it with gloved fingers.

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

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

A 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.

When caring for a client with dentures, what should the nurse teach the client?

Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit.

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.

Which statement accurately describes a recommended step when making an unoccupied bed?

Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side.

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?

Normal saline

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

Periodontitis

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

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

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

The 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 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.

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

Use a tepid bath to relieve inflammation and itching.

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

Use electric razor for shaving purposes.

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.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect

alopecia

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

how often the client is bathing.

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

increased circulation

A kindergarten student is sent to the school nurse because they have 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 (lice)

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?

the importance of completely finishing the prescribed treatment

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