Deck 19: Assisting with Hygiene Personal Care Skin Care and the Prevention of Pressure Ulcers

Question 1

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should:

A) massage the areas vigorously to restore circulation to the pressured areas.
B) document that the patient has a stage I pressure ulcer of the right shoulder and hip.
C) not position the patient on the right side for at least 8 hours.
D) reassess the area after 30 to 45 minutes for reactive hyperemia.

Answer 1

reassess the area after 30 to 45 minutes for reactive hyperemia.

Question 2

When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to:

A) call his primary care provider about the amount of exertion in physical therapy.
B) suggest the patient walks slowly in the hall to "cool down."
C) offer additional fluids to replace those lost through normal cooling.
D) place a light cover over the patient to prevent his chilling.

Answer 2

offer additional fluids to replace those lost through normal cooling.

Question 3

When instructing a nursing assistant about hygiene needs of a frail older adult patient, the nurse correctly educates the nursing assistant to:

A) "Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling."
B) "Put bath oil in the tub and use plenty of soap to really clean the patient's skin while she is in the tub."
C) "Use brisk drying and an alcohol rub to close the patient's pores and prevent heat loss after the bath."
D) "Completely dry the patient's skin and apply a mild moisturizer."

Answer 3

"Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling."

Question 4

It is most important for the nurse to write specific personal care plan modifications for the patient who:

A) is 76 years old, alert, oriented, and able to provide his own care.
B) had a hip replacement 2 years ago and uses a cane to ambulate.
C) has an artificial eye and poor vision in the other.
D) prefers a tub bath to a shower, preferably before bedtime.

Question 5

In assessing the skin condition of an older adult patient, the nurse notes that, over the sacral area, there is a 2 cm * 3 cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

A) "Patient has stage II ulcer on sacrum. No blanching of perimeter."
B) "Reddened area over sacrum, skin open in center."
C) "Pressure ulcer on sacrum. Massaged with no improvement in color."
D) "2 cm * 3 cm reddened area on sacrum with open center. Does not blanch."

Question 6

The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:

A) scar formation at the injury site resulting from the healing process.
B) infection with bacteria or viruses that may affect the person systemically.
C) loss of sensation caused by damage to the nerves in the area.
D) loss of body fluids and an upset in the fluid and electrolyte balance.

Question 7

The nurse caring for a patient who is not taking any food or fluids by mouth because he is unconscious is aware that the patient:

A) does not need mouth care as frequently as the patient who is eating and drinking.
B) should have complete mouth care once a day when the nurse assesses the condition of his skin and mucous membranes.
C) needs to have his mouth swabbed to moisten and remove secretions every 4 hours.
D) should have his lips lubricated and his teeth brushed with mouthwash once a shift.

Question 8

A nurse is preparing to give a complete bed bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse:

A) washes each eye with a fresh area of the washcloth before washing the rest of the patient's face.
B) wears protective gloves throughout the entire procedure.
C) begins with a back wash and rub to assess for pressure areas over the sacrum.
D) changes the water after washing the patient's face, and again after washing his back.

Question 9

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak?

A) Perform a full bed bath, brush and floss his teeth, and give him a good back massage.
B) Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary.
C) Set up a washbasin and supplies, tell the patient to wash what he can, and provide privacy for the patient to do what he can.
D) Teach a family member to give a full bath so that the family member will be able to care for the patient at home.

Question 10

When providing perineal care for an uncircumcised male patient, the nurse:

A) provides perineal care the same as for a circumcised male.
B) ensures that the foreskin is retracted and the glans is exposed at the end of the procedure.
C) does not touch the glans during the procedure because it is very sensitive.
D) retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure.

Question 11

Because the older adult patient lies curled up in a side lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the:

A) sacrum.
B) heels.
C) ilium.
D) scapula.

Question 12

A 20-year-old male patient is admitted after an auto accident. He has blood and dirt matted in his hair. The nurse should:

A) blot the tangled, bloodied hair and then provide a bed shampoo to remove the remaining dirt and debris.
B) comb the tangles out with a fine toothed comb, starting at the scalp and working down to the ends of the strands.
C) remove tangles by using alcohol or water on small sections of hair, holding the hair between the scalp and the area the nurse is brushing or combing.
D) shampoo the hair as well as possible and leave the tangles alone.

Question 13

A patient who has a dry, itchy dermatitis will most likely benefit from:

A) an oatmeal or starch therapeutic bath with tepid water.
B) having his skin patted with alcohol to decrease the itching.
C) a very warm whirlpool bath for 20 to 30 minutes.
D) avoiding any skin contact with water in the affected areas.

Question 14

An important factor to consider when assessing the hygiene needs of a patient is that:

A) the patient knows best what is needed in his hygiene routine.
B) the routine of the agency will determine when the patient is able to bathe.
C) hygiene is not as important as other needs of the patient.
D) the patient may not have the same hygiene practices as the nurse.

Question 15

The nurse assessing for a pressure ulcer in a patient with darkly pigmented skin should:

A) examine the area under full florescent light.
B) look for a purple hue under natural light.
C) reassess areas that appear lighter under a halogen light.
D) identify areas of a green hue under a halogen light.

Question 16

Providing oral care to a patient who has dentures includes:

A) asking the patient to place his teeth directly in a covered, labeled container for overnight storage.
B) removing, cleaning, and storing the dentures in a labeled container at bedtime.
C) cleaning the dentures in hot water after each meal to remove debris and bacteria.
D) using a tooth brush and toothpaste to clean the dentures in the patient's mouth.

Question 17

The patient most at risk for a pressure ulcer would be:

A) a 46-year-old man in traction for a fractured femur, who exercised regularly before his accident and is alert and oriented.
B) a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed.
C) a 72-year-old man admitted for elective surgery to replace his hip joint, who was an avid bowler and gardener before his hip disease slowed him down.
D) an 84-year-old man with Alzheimer disease who is pacing in the halls and who is incontinent of urine if not toileted every 2 hours.

Question 18

To perform oral care for an unconscious patient, the nurse takes which action first?

A) Position the patient in an upright sitting position with the bed at a comfortable working height for the nurse.
B) Raise the bed to a comfortable working height and position the patient in a flat side lying position.
C) Move the patient to the far edge of the bed with the head slightly elevated.
D) Lower the bed, lower both side rails, and turn the patient's head to one side.

Question 19

A patient has a quarter sized blackened eschar on both heels surrounded by a 1 to 2 cm indurated reddened area. The nurse is aware that these lesions are:

A) pressure ulcers that cannot be accurately staged because of the eschar.
B) stage I pressure ulcers because of the induration and redness.
C) stage II pressure ulcers because the skin has been broken.
D) stage III or IV pressure ulcers because of the eschar.

Question 20

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the:

A) patient will shower daily on an independent basis by the end of 1 month.
B) nurse will give a tub bath or full bed bath daily.
C) patient will shower or tub bathe with assistance twice a week.
D) patient will tub bathe or shower with assistance daily.

Question 21

Skin that is frequently wet leads to _______________, the softening of tissue that increases the chance of trauma or infection.

Question 22

A nurse admitting a 76-year-old patient to the unit carefully documents the appearance of a Stage III pressure ulcer and informs the charge nurse because:

A) the presence of an ulcer suggests previous lack of care.
B) the charge nurse will need to report the presence of the ulcer.
C) Medicare will reimburse the facility if the ulcer advances.
D) documentation of a Stage III ulcer on admission is part of good assessment.

Question 23

One of the facility's unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to:

A) use an emery board to smooth the nail edges.
B) use scissors to round off the nail near the end of the toe.
C) apply lotion to the feet and apply bed socks.
D) cut the nail straight across with a nail clipper.

Question 24

A nurse is instructing a nursing student regarding prevention of pressure ulcers. The nurse would recognize further instruction is warranted when the nursing student states, "I will:

A) position the patient directly on the trochanter."
B) use a written schedule for turning and repositioning."
C) gently rub around a reddened area to restore circulation."
D) wash and dry the incontinent patient promptly."

Question 25

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to:

A) leave the contacts in place for up to a month.
B) use a lens suction cup to remove the lens.
C) request an ophthalmologist (eye specialist) to come in to remove the lenses.
D) irrigate the eye with saline until the lens floats out.

Question 26

The changes in the integumentary system that are part of the normal aging process are: (Select all that apply.)

A) hair becomes thin and grows more slowly.
B) temperature control is altered because of the increased sebaceous gland activity.
C) skin is more fragile because of loss of collagen fibers.
D) skin wrinkles and sags.
E) nail growth increases.

Question 27

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have:

A) mottled skin and induration.
B) full-thickness skin loss and a deep crater.
C) partial thickness skin loss with the appearance of a blister.
D) a deep pink area of unblanchable skin.

Question 28

A patient with insulin-dependent diabetes has a below the knee amputation on the right leg. What modification of his personal care is noted as most important?

A) Perineal care should be performed at least twice a day to prevent urinary tract infections.
B) A safety razor should not be used for shaving; an electric razor should be used.
C) The patient should be assisted to the shower, where he can use a shower chair.
D) The patient's left foot should be soaked and gently dried, but his toenails should not be cut.

Question 29

The buildup of tough necrotic tissue found with a pressure ulcer is called _________.

Question 30

The culturally sensitive nurse caring for a Muslim woman who has noticeable body odor as well as abundant underarm hair should:

A) use soap and water under the arms.
B) apply a cream-type deodorant.
C) shave the underarms.
D) cut hair close to the armpit with scissors.

Question 31

Which of the following are main functions of the skin? (Select all that apply.)

A) Protection
B) Warmth
C) Excretion
D) Sensation
E) Secretion
F) Cleansing

Question 32

A nurse notes that her patient has an area of intact, red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage:

A) I pressure ulcer.
B) III pressure ulcer.
C) IV pressure ulcer.
D) II pressure ulcer.

Question 33

When the nurse is assisting a male patient to shave his face, it is most important for her to:

A) practice on a male friend or relative before trying it on a patient.
B) have the patient shave first before any other hygiene measures are performed.
C) be sure the patient knows to draw the razor in the direction the hair grows.
D) check whether a safety razor can be used or whether it is contraindicated.

Question 34

A stage III pressure ulcer is indicated by: (Select all that apply.)

A) full-thickness skin loss.
B) widespread infection.
C) drainage from the ulcer.
D) damaged subcutaneous tissue.
E) induration.
F) warmth of surrounding tissue.

Question 35

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to:

A) remove secretions that might block respiratory passages.
B) remove emesis if the patient should vomit.
C) prevent fluids from collecting in the patient's mouth and being aspirated.
D) stimulate the patient's gums and mucous membrane.

Question 36

The nurse shampooing the hair of an African American takes into consideration that the hair:

A) is oilier than the hair of whites.
B) should only be washed every 7 to 10 days.
C) should be dried with a hair dryer.
D) should be combed with a fine toothed comb.

Question 37

A usual routine for providing nail care to a patient includes:

A) soaking the nails in warm soapy water to soften before cleaning under the nail edge with an orangewood stick.
B) gently cleaning under the nails with a metal file to remove dirt and dead skin and then soaking hands or feet afterward.
C) cutting toenails with rounded edges to prevent scratching or ingrown nails.
D) cutting toenails and fingernails every 2 or 3 days to keep them short and clean.