Deck 40: Hygiene

Question 1

The nurse is bathing a patient and notices movement in the patient's hair. Which action will the nurse take?

A) Use gloves to inspect the hair.
B) Apply a lindane-based shampoo immediately.
C) Shave the hair off of the patient's head.
D) Ignore the movement and continue.

Answer 1

Use gloves to inspect the hair.

Question 2

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action?

A) Inadequate blood flow leads to decreased tissue ischemia.
B) Patients with limited caloric intake develop thicker skin.
C) Pressure reduces circulation to affected tissue.
D) Verbalization of skin care needs is decreased.

Answer 2

Pressure reduces circulation to affected tissue.

Question 3

When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?

A) Fungi
B) Friction
C) Nail polish
D) Nail polish remover

Answer 3

Fungi

Question 4

The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

A) Patients who appear unkempt place little importance on hygiene practices.
B) Personal preferences determine hygiene practices and are unchangeable.
C) The patient's illness may require teaching of new hygiene practices.
D) All cultures value cleanliness with the same degree of importance.

Question 5

The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?

A) Cheilitis
B) Halitosis
C) Glossitis
D) Dental caries

Question 6

The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel?

A) Providing nail care
B) Teaching foot care
C) Making an occupied bed
D) Determining aspiration risk

Question 7

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care?

A) Hygiene care is always routine and expected.
B) No two individuals perform hygiene in the same manner.
C) It is important to standardize a patient's hygienic practices.
D) During hygiene care do not take the time to learn about patient needs.

Question 8

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

A) Assess surfaces exposed to the edges of the cast for pressure areas.
B) Keep the patient's blood pressure low to prevent overperfusion of tissue.
C) Do not allow turning in bed because that may lead to redislocation of the leg.
D) Restrict the patient's dietary intake to reduce the number of times on the bedpan.

Question 9

A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

A) Adolescent
B) Preschooler
C) Older adult
D) Adult

Question 10

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care?

A) Decreased pain sensation and increased risk of skin impairment
B) Decreased caloric intake and accelerated wound healing
C) High risk for skin infection and low saliva pH level
D) High risk for impaired venous return and dementia

Question 11

After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe?

A) Corns
B) A callus
C) Plantar warts
D) Athlete's foot

Question 12

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best?

A) Defer the bath until evening and pass on the information to the next shift.
B) Tell the patient that daily morning baths are the "normal" routine.
C) Explain the importance of maintaining morning hygiene practices.
D) Cancel hygiene for the day and attempt again in the morning.

Question 13

When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse's action?

A) Outer skin layer becomes more resilient.
B) Less frequent bathing may be required.
C) Skin becomes less subject to bruising.
D) Sweat glands become more active.

Question 14

The nurse is caring for a patient who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns, but they seem to be getting worse. Which information will the nurse share with the patient?

A) Corn pads are an adequate treatment and should be continued.
B) The patient should avoid soaking the feet before using a pumice stone.
C) Depending on severity, surgery may be needed to remove the corns.
D) Tighter shoes would help to compress the corns and make them smaller.

Question 15

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

A) A patient who is afebrile
B) A patient who is diaphoretic
C) A patient with strong pedal pulses
D) A patient with adequate skin turgor

Question 16

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

A) Stand to the side of the patient's eye and observe the cornea.
B) Conclude that the glasses were lost during the accident.
C) Notify the ambulance personnel for missing glasses.
D) Ask the patient where the glasses are.

Question 17

A nurse is completing an assessment of the patient. Which principle is a priority?

A) Foot care will always be important.
B) Daily bathing will always be important.
C) Hygiene needs will always be important.
D) Critical thinking will always be important.

Question 18

Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

A) Insert an indwelling urinary catheter.
B) Limit caloric and protein intake.
C) Turn the patient every 2 hours.
D) Assess for pain during a bath.

Question 19

The patient is diagnosed with athlete's foot (tinea pedis). The patient says that he is relieved because it is only athlete's foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient?

A) Contagious with frequent recurrences
B) Helpful to air-dry feet after bathing
C) Treated with salicylic acid
D) Caused by lice

Question 20

The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve?

A) Prevention of plantar warts
B) Prevention of foot fungus
C) Prevention of neuropathy
D) Prevention of amputation

Question 21

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

A) Back to front
B) In a circular motion
C) From pubic area to rectum
D) Upward from rectum to pubic area

Question 22

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

A) Use blunt tweezers and pull upward with steady pressure.
B) Burn the ticks with a match or small lighter.
C) Allow the ticks to drop off by themselves.
D) Apply miconazole and cover with plastic.

Question 23

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

A) Should be postponed because it may cause embarrassment
B) Should be unnecessary because the patient is uncircumcised
C) Should be done by the patient
D) Should be done by the nurse

Question 24

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

A) Using waxed floss prevents bleeding.
B) Flossing removes plaque and tartar from the teeth.
C) Performing flossing at least 3 times a day is beneficial.
D) Applying toothpaste to the teeth before flossing is harmful.

Question 25

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
1) Roof of mouth, gums, and inside cheek
2) Chewing and inner tooth surfaces
3) Outer tooth surfaces
4) Tongue

A) 4, 1, 3, 2
B) 3, 2, 4, 1
C) 2, 3, 1, 4
D) 1, 4, 2, 3

Question 26

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

A) Do not place slippers on the patient's feet.
B) Trim the patient's toenails daily.
C) Report sores on the patient's toes.
D) Check the brachial artery.

Question 27

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

A) Bag bath
B) Sponge bath
C) Partial bed bath
D) Complete bed bath

Question 28

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?
1) Neck, shoulders, and chest
2) Abdomen and groin/perineum
3) Legs, feet, and web spaces
4) Back of neck, back, and then buttocks
5) Both arms, both hands, web spaces, and axilla

A) 5, 1, 2, 3, 4
B) 1, 5, 2, 3, 4
C) 1, 5, 2, 4, 3
D) 5, 1, 2, 4, 3

Question 29

The nurse is providing oral care to an unconscious patient. Which action should the nurse take?

A) Moisten the mouth using lemon-glycerin sponges.
B) Hold the patient's mouth open with gloved fingers.
C) Use foam swabs to help remove plaque.
D) Suction the oral cavity.

Question 30

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

A) Avoid commercial mouthwashes.
B) Avoid normal saline rinses.
C) Brush with a hard toothbrush.
D) Brush with an alcohol-based toothpaste.

Question 31

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

A) Insert an oral airway.
B) Place the patient in a flat, supine position.
C) Use undiluted hydrogen peroxide as a cleaner.
D) Quickly proceed while not talking to the patient.

Question 32

A nurse is providing AM care to patients. Which action will the nurse take?

A) Soaks feet of patient with peripheral vascular disease
B) Applies CHG solution to wash perineum of patient with a stroke
C) Cleanses eye from outer canthus to inner canthus of patient with diabetes
D) Uses long, firm stroke to wash legs of patient with blood-clotting disorder

Question 33

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?
1) Face
2) Eyes
3) Perineum
4) Arm and chest
5) Hands and nails
6) Back and buttocks
7) Abdomen and legs

A) 1, 2, 5, 4, 7, 6, 3
B) 2, 1, 4, 5, 7, 3, 6
C) 2, 1, 5, 4, 6, 7, 3
D) 1, 2, 4, 5, 3, 7, 6

Question 34

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority?

A) Feet
B) Nail beds
C) Perineum
D) Oral cavity

Question 35

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

A) Dandruff
B) Alopecia
C) Pediculosis
D) Xerostomia

Question 36

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

A) Assess oral cavity.
B) Assess room for drafts.
C) Assess ankles for edema.
D) Assess for reduced sensations.

Question 37

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

A) Not offering a backrub to a patient with fractured ribs
B) Not offering to wash the hair of a patient with neck trauma
C) Turning off the television while giving a backrub to the patient
D) Turning patient's head with neck injury to side when giving oral care

Question 38

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do?

A) Rinse thoroughly.
B) Allow the skin to air-dry.
C) Do not use a bath towel.
D) Dry the skin with a towel.

Question 39

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?

A) Leave the foreskin alone because there is little chance of infection.
B) Retract the foreskin for cleansing and allow it to return on its own.
C) Retract the foreskin and return it to its natural position when done.
D) Leave the foreskin retracted.

Question 40

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

A) Treatment is use of regular shampoo.
B) Products containing lindane are most effective.
C) Head lice may spread to furniture and other people.
D) Manual removal is not a realistic option as treatment.

Question 41

A patient uses an in-the-canal hearing aid. Which assessment is a priority?

A) Eyeglass usage
B) Cerumen buildup
C) Type of physical exercise
D) Excessive moisture problems

Question 42

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next?

A) Teach the patient how to use cotton-tipped applicators.
B) Tell the patient to use a bobby pin to extract earwax.
C) Apply gentle, downward retraction of the ear canal.
D) Instill hot water into the ear canal to melt the wax.

Question 43

The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session?

A) Use tap water to clean soft lenses.
B) Wash and rinse lens storage case daily.
C) Reuse storage solution for up to a week.
D) Keep the lenses is a cool dry place when not being used.

Question 44

The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.)

A) Abnormal gait
B) Foot deformities
C) Absent or decreased pedal pulses
D) Muscle wasting of lower extremities
E) Decreased hair growth on legs and feet

Question 45

A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.)

A) Do not rinse.
B) Clean under breasts.
C) Inform that the skin will feel sticky.
D) Dry thoroughly between skin folds.
E) Use two wipes for each area of the body.

Question 46

Which patients will the nurse determine are in need of perineal care? (Select all that apply.)

A) A patient with rectal and genital surgical dressings
B) A patient with urinary and fecal incontinence
C) A circumcised male who is ambulatory
D) A patient who has an indwelling catheter
E) A bariatric patient

Question 47

The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide?

A) Change the battery every day or as needed.
B) Adjust the volume for a talking distance of 1 yard.
C) Wear the hearing aid 24 hours per day except when sleeping.
D) Avoid the use of hairspray, but aerosol perfumes are allowed.

Question 48

The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

A) Use gentle suction to prevent tissue damage.
B) Instruct patient to blow nose forcefully to clear the passage.
C) Place a dry washcloth under the nose to absorb secretions.
D) Insert a cotton-tipped applicator to the back of the nose.

Question 49

The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.)

A) Administer ordered analgesic 1 hour before bath time.
B) Increase the frequency of skin assessment.
C) Reduce triggers in the environment.
D) Keep the room temperature cool.
E) Be as quick as possible.

Question 50

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)

A) Apply sterile gloves.
B) Keep soiled linen close to uniform.
C) Advise patient will feel a lump when rolling over.
D) Turn clean pillowcase inside out over the hand holding it.
E) Make a modified mitered corner with sheet, blanket, and spread.