Chapter 24. Hygiene – Flashcards
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The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? Teach the patient to: 1) use an electric razor for shaving. 2) apply skin moisturizer. 3) use less soap when bathing. 4) floss teeth daily.
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ANS: 1 The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss. PTS: 1 DIF: Easy REF: p. 702 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
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The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient. 2) Use cool water for bathing. 3) Provide care in small intervals. 4) Rub briskly when towel drying.
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ANS: 3 The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure. PTS: 1 DIF: Difficult REF: pp. 685-686 - answer is not expressly given. KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
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A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Total Self-care Deficit 2) Bathing/Hygiene Self-care Deficit 3) Dressing/Grooming Self-care deficit 4) Activity Intolerance
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ANS: 2 The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patient's inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario. PTS: 1 DIF: Moderate REF: ESG, Chapter 24, "Standardized Language," Table: "Selected Standardized Outcomes and Interventions for Self-Care" KEY: Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level: Analysis
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Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care
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ANS: 4 The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation. During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing. Early morning care typically consists of assisting with toileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and hair care. It may also include dressing and positioning or assisting the patient to the chair. PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension
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For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion
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ANS: 3 Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly. PTS: 1 DIF: Difficult REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
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A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1) Risk for Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity
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ANS: 2 The epidermis contains melanin, a pigment that protects against the sun's ultraviolet rays; therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn (actual Impaired Skin Integrity), only that a risk factor is present. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection. PTS: 1 DIF: Difficult REF: pp. 688 for coverage of aging effects including loss of melanin, 689 for coverage of impaired skin integrity; students must synthesize the information to answer the question; answer is not directly stated in text KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
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What is the body's first line of defense against bacteria? 1) Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response
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ANS: 1 Intact skin is the body's first line of defense against bacteria. Once bacteria enter the body, the inflammatory response, white blood cells, and lymph glands play a role in fighting against the bacteria. PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
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While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Pallor. 2) Erythema. 3) Jaundice. 4) Cyanosis.
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ANS: 3 A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver function. Pallor is pale skin without underlying pink tones in the light-skinned person. Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor peripheral circulation or decreased oxygen in the blood. PTS: 1 DIF: Moderate REF: p. 688 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
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A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) The epidermal layer of skin was rubbed away. 4) A lesion caused by tissue compression was present.
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ANS: 2 Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility. PTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
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For which patient is it most important to provide frequent perineal care? The patient: 1) with active lower gastrointestinal bleeding. 2) after an episode of diabetic ketoacidosis. 3) who has a circumcised penis. 4) with a history of acute asthma.
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ANS: 1 The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care. PTS: 1 DIF: Moderate REF: pp. 692, 714-716 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
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A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into the bathtub. 2) Wait for the patient to calm down, and then give him a towel bath. 3) Allow the patient to go without bathing for a day or two. 4) Ask another staff member to attempt the tub bath.
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ANS: 2 Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patient's agitation, as consistency of caregivers is important for patients with dementia. PTS: 1 DIF: Moderate REF: pp. 692-693 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
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The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? 1) "Cleanse only those areas likely to cause odor." 2) "Provide the patient with warm water for washing his perineum." 3) "Wash the patient's back, buttocks, and perineum first." 4) "Bathe the patient from head-to-toe, cleanest areas first."
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ANS: 4 The nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm water and allow him to wash his perineum when giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of "clean to dirty." PTS: 1 DIF: Moderate REF: pp. 690-691; 707-711 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
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Which action should the nurse take when preparing a patient for a bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from the bed. 3) Have the patient completely bathe himself to promote independence. 4) Wash the patient's body without assistance from the patient.
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ANS: 1 When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an assist bath. PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension
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A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath
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ANS: 3 A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patient's energy. PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
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Wearing poorly fitting shoes may result in which condition? 1) Tinea pedis 2) Plantar wart 3) Excoriation 4) Ingrown toenail
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ANS: 4 Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes come in contact with skin. PTS: 1 DIF: Moderate REF: p. 694 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
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. The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1) "I can contract the infection by walking barefoot in the gymnasium's showers." 2) "The best way to avoid contracting the infection is to use good hand washing." 3) "Wearing unventilated shoes prevents the fungus from gaining contact with my feet." 4) "There is really no way to prevent its spread; it's highly contagious."
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ANS: 1 One can contract the infection by walking barefoot in public showers, such as those in the school's gymnasium. Good hand washing does not prevent a person from contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. Although the infection is highly contagious, the spread of infection can be prevented by wearing special footwear in the shower. PTS: 1 DIF: Moderate REF: p. 694 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
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Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? 1) 99°F (37.2°C) 2) 102°F (38.9°C) 3) 103°F (39.4°C) 4) 105°F (40.6°C)
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ANS: 4 Bath water temperature should be 105°F (40.6°C) to prevent chilling, burning, and excess drying of the skin. PTS: 1 DIF: Easy REF: p. 707 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
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While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest? 1) Inadequate dietary intake 2) Normal aging process 3) Fungal infection 4) Excessive use of silver salts
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ANS: 1 Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish gray discoloration of the nail plate signals excessive intake of silver salts. PTS: 1 DIF: Moderate REF: p. 695 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
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A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1) Dryness of the mouth 2) Bitter taste 3) Demineralization of the tooth enamel 4) Gingival hyperplasia
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ANS: 4 Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause dry mouth. Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel. PTS: 1 DIF: Moderate REF: p. 698 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
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The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care? 1) Supine 2) Prone 3) Semi-Fowler's 4) Side-lying
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ANS: 4 The nurse should position an unconscious patient in a side-lying position to provide mouth care to prevent aspiration. Supine, prone, and semi-Fowler's positions are unsafe positions for providing mouth care for the unconscious patient. PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension
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Which item is best for providing mouth care for an unconscious patient? 1) Foam swabs 2) Lemon-glycerin swabs 3) Hydrogen peroxide 4) Cotton-tipped applicator soaked in mouthwash
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ANS: 1 Commercially packaged applicators or foam swabs are typically used to provide mouth care. Lemon-glycerin swabs are not recommended because they are drying to the oral mucosa. Hydrogen peroxide should be avoided because it is irritating to oral mucosa and may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by conscious patients as part of their routine mouth care. However, cotton-tipped applicators should not be soaked in it to perform mouth care. PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall
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After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1) pediculosis. 2) alopecia. 3) dandruff. 4) hirsutism.
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ANS: 2 Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women. PTS: 1 DIF: Moderate REF: p. 702 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
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Which of the following is a correct step in removing and cleaning a hearing aid? 1) Clean only the external surfaces, not the canal portion. 2) Clean the top part of the canal portion of the device. 3) Insert a wax loop or toothpick into the hearing aid. 4) Remove the battery before taking the hearing aid from the ear.
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ANS: 2 The nurse should clean the top part of the canal portion of the hearing aid using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. Nothing should be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth. The hearing aid should be turned off before removing it from the ear, but the battery is not removed at that step of the procedure. It would not likely be possible to remove the battery while the device was still in the ear. PTS: 1 DIF: Difficult REF: pp. 739-742 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
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The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient's artificial eye. What should the nurse do to best position the patient for this procedure? Ask the patient to: 1) Lean forward and rest the arms on the overbed table. 2) Sit back in the chair and tilt the head back. 3) Move to the bed and lie down. 4) Stand up and lean over the bed.
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ANS: 3 The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall onto the bed instead of the floor. Sitting back in the chair would allow access to the eye but would not protect the artificial eye from falling to the floor. Leaning forward and resting the arms on an overbed table, as well as standing up and leaning over the bed, would not provide the nurse access to the eye to remove the prosthesis. PTS: 1 DIF: Moderate REF: p. 739 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
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Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. 1) Buccal mucosa 2) Around the lips 3) Palms 4) Tongue
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ANS: 1, 3, 4 In dark-skinned people, cyanosis can be best assessed by examining the palms of the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be used. PTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
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Which of the following is/are a benefit of bathing? Choose all that apply. 1) Constricts blood vessels 2) Increases depth of respirations 3) Gives opportunity for assessments 4) Reduces sensory input
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ANS: 2, 3 Bathing presents an opportunity to perform a variety of assessments. Bathing also dilates blood vessels near the skin's surface, increasing circulation. Moreover, bathing stimulates the depth of respirations and provides sensory input. PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
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For which patient(s) should the nurse avoid using back massage? One who (select all that apply): 1) underwent heart surgery 3 days ago. 2) sustained rib fractures from a fall. 3) underwent a lumbar laminectomy. 4) sustained a leg fracture in a sledding accident.
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ANS: 1, 2 Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or leg fracture. PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
