Deck 39: Hygiene

Question 1

A client receiving chemotherapy is experiencing stomatitis.The nurse advises the client to use:
1) A commercial mouthwash
2) An alcohol and water mixture
3) Normal saline rinses
4) A firm toothbrush

Answer 1

3
Normal saline rinses (approximately 30 mL)on awaking in the morning,after each meal,and at bedtime can effectively clean the oral cavity.The rinses can be increased to every 2 hours if necessary.Clients with stomatitis should be advised to avoid commercial mouthwash.Clients with stomatitis should be advised to avoid alcohol.Gentle brushing and flossing are important in preventing bleeding of the gums.A soft toothbrush,not a firm toothbrush,should be used.

Question 2

A client who is suspected of having vascular insufficiency to the lower extremities is assessed by the nurse to have a(n):
1) Increased hair growth on the legs and feet
2) Dull appearance of the skin
3) Erythema upon elevation of the feet
4) Diminished pedal pulses

Answer 2

4
The client with vascular insufficiency of the lower extremities may exhibit diminished pedal pulses.The client with vascular insufficiency of the lower extremities would have decreased hair growth on the legs and feet,not increased hair growth.The client with vascular insufficiency typically has a shiny appearance of the skin of the lower extremities.The client with vascular insufficiency characteristically demonstrates blanching of the skin on elevation.

Question 3

The nurse is preparing to assist the adult female client with perineal care.The position of choice for this client is:
1) Dorsal recumbent
2) Side-lying
3) Supine
4) Prone

Answer 3

1
To perform female perineal care,the client should be assisted to the dorsal recumbent position.Side-lying is not the position of choice for performing perineal care of the female client.The supine position is the position of choice for performing perineal care of the male client,not the female.The prone position is not the position of choice for performing perineal care of the female client.

Question 4

The nurse delegates morning care to a new certified nursing assistant.Which of the following actions by the assistant would be evaluated as appropriate?
1) Placing dentures in a tissue while not worn
2) Cutting the client's nails with scissors
3) Using soap to cleanse the eye orbits
4) Washing the client's legs with long strokes from the ankle to the knee

Question 5

A client has severe right-sided weakness and is unable to complete bathing and grooming independently.Based on this observation,the nurse identifies a nursing diagnosis of:
1) Powerlessness
2) Self-care deficit
3) Tissue integrity impairment
4) Knowledge deficit of hygiene practices

Question 6

The nurse is instructing the client with peripheral vascular disease about daily foot care.The nurse's instruction for the client includes:
1) Soaking the feet 5 to 10 minutes each day
2) Filing the nails into a curve shape
3) Using commercial corn removers if needed
4) Applying lamb's wool between the toes

Question 7

The nurse is completing a bed bath for a dependent adult male client.During the perineal care,the client has an erection.The nurse should:
1) Continue with the perineal care
2) Tell the client it's okay and just to relax
3) Ask the client to try and do the care as well as he can
4) Defer the care until a little later in the bath

Question 8

The nurse has delegated the task of bathing a semicomatose client to ancillary personnel.The nurse suggests that the personnel multitask while completing the bath.Which of the following would be the most appropriate intervention for the ancillary personnel to accomplish while bathing this particular client?
1) Oral hygiene care
2) Moisturizing hands and feet
3) Passive range of motion exercises
4) Care of the client's intravenous site

Question 9

The client has a red,raised skin rash.During the bath,the priority action of the nurse is to:
1) Assess for further inflammatory reactions
2) Discuss the body image problems created by the presence of the rash
3) Wash the skin thoroughly with hot water and soap
4) Moisturize the skin to prevent drying

Question 10

A different approach to traditional hygienic care is the "bag bath." The best rationale for using this approach is because it is:
1) Less expensive than the traditional method
2) Takes less time to complete
3) Leaves the skin softer
4) Reduces the risk of infection

Question 11

A 61-year-old client with diabetes mellitus has physician's orders for meticulous foot care.Which of the following is the best rationale for the order?
1) The aging process causes increased skin breakdown.
2) There is increased neuropathy with this pathology that places the client at risk.
3) The client probably has a history of poor hygienic care.
4) The lower extremities are difficult to see and therefore hard to maintain with good hygiene.

Question 12

The client is unable to rest even after medication.The nurse decides to give the client a backrub.Which of the following strokes should the nurse use when finishing the backrub?
1) Long,firm strokes down the back
2) Light strokes while moving up the back in a circular motion
3) Kneading movements toward the sacrum
4) Circular motion upward from buttocks to shoulders

Question 13

Which of the following statements best reflects the nurse's knowledge of the affect of skin integrity on a client's general state of health?
1) "When I keep the skin healthy,the client is healthy."
2) "If the skin isn't in good shape,illness isn't far away."
3) "I believe cleanliness is a top priority for comfort and health."
4) "If a client is able to do their own hygiene care,they feel in control."

Question 14

To administer oral care to a semi-comatose client,the nurse should place the client in which of the following positions?
1) Reverse Trendelenburg
2) High Fowler's with the head to the side
3) Side-lying with the head turned toward the nurse
4) Supine with the neck slightly forward

Question 15

The client is unable to perform self-care for the hair.The nurse is aware that which of the following is accurate when performing hair care?
1) Brushing the hair distributes the natural oils evenly.
2) Using a hot comb may be very helpful for straight and oily hair.
3) Very tight braids keep the hair in good condition.
4) Shampooing should be done daily.

Question 16

The nurse delegates the hygienic care of a male client to the nursing assistant.In reviewing the client assignment,the nurse instructs the assistant to make sure to use an electric razor to shave the client with:
1) Thrombocytopenia
2) Congestive heart failure
3) Osteoarthritis
4) Pneumonia

Question 17

An adolescent client with acne should be taught by the nurse to:
1) Apply moisturizing lotions or creams
2) Wash the face and hair daily with very warm water and soap
3) Use a depilatory to remove excess hair
4) Add moisture to the air with the use of a humidifier

Question 18

A client has recently experienced difficulty hearing out of both ears.Which of the following is the best nursing response to the client?
1) "Let's irrigate your ears with cool water."
2) "Can you turn your head toward me when I am talking to you?"
3) "Your hearing aid should not need a new battery for at least 3 months."
4) "Try to avoid putting a Q-Tip (cotton-tipped applicator)into your ears."

Question 19

Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?
1) "I work with my ancillary staff to be able to determine what is abnormal."
2) "The skin is easy to observe for abnormalities when you are giving the bath."
3) "I use the time to really look at my clients and determine what's normal and what's not."
4) "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."

Question 20

The nurse is caring for a client who has right-sided paralysis following a stroke.Which of the following factors would be most likely to result in decubitus ulcer formation for this client?
1) Poor nutrition
2) Immobility
3) Reduced hydration
4) Skin secretions

Question 21

The nurse best displays an understanding of the role the skin plays in monitoring the body systems and their ability to function properly when documenting which of the following regarding a 70-year-old client?
1) Skin appears generally jaundiced.
2) Dryness noted on heels and elbows bilaterally.
3) Skin tears present on upper left and right arms.
4) Skin on the hands and feet is slightly cool to the touch.

Question 22

The nurse is discussing hygiene issues with a group of mothers with young school-age children.When discussing the topic of head lice (pediculosis capitis),the nurse realizes that the most important motivation for preventing and/or managing this condition is that:
1) The lice may carry various other serious diseases
2) The parasites are extremely difficult to remove and kill
3) The presence of lice typically reflects poor hygiene practices
4) The parasites are easily transferable from one person to another

Question 23

Which of the following statements made by ancillary personnel regarding the bathing of a 79-year-old client requires immediate follow-up by the nurse?
1) "At times you have to really work at getting her to agree to having a bath."
2) "I learned that an evening bath is what she is used to,so I'll bathe her before bed."
3) "She seemed to enjoy her morning bath;I'll bathe her again this evening after dinner."
4) "She really enjoys that mildly scented vanilla soap her daughter brought her yesterday."

Question 24

A client with darkly pigmented skin reports that the intravenous site is "uncomfortable." To thoroughly assess the complaint of this particular client,the nurse should:
1) Determine when the angiocatheter was inserted
2) Ask the client if the area appears reddened
3) Take an axillary temperature on the same side as the IV site
4) Use the back of the hand to assess skin temperature at the site

Question 25

The nurse is discussing nail care with a group of teenage girls.Which of the following statements made by one girl in the audience requires immediate follow-up by the nurse?
1) "My mother tells me that toe rings will cause me to develop calluses."
2) "It's expensive buying new shoes just because your feet keep growing."
3) "I throw my sneakers into the washing machine regularly to keep the inside surfaces clean."
4) "I cut the discolored nails on both of my great toes really short to make them a little less noticeable."

Question 26

On examining a client's fingernails,the nurse notes that they are excessively dry.The nurse knows that this can be caused by which of the following?
1) Fungal nail infections
2) Dry climates
3) Washing dishes by hand
4) Polishing nails,and using polish remover

Question 27

Which of the following assessment questions is most likely to determine the reason an older adult client refuses to remove and brush his dentures?
1) "Why are you being difficult about cleaning your dentures?"
2) "Will you allow me to clean your denture if you don't want too?"
3) "Are you concerned about damaging your dentures if you take them out?"
4) "Do you realize the problems that can occur when your dentures aren't clean?"

Question 28

The nurse is discussing skin care with a group of early teens (ages 13 to 15).Which of the following is the most therapeutic response to the question,"How can I keep from getting bad skin?"
1) "Bad skin is a part of being a teenager;but don't make it worse with poor hygiene habits."
2) "Bad skin is often affected by what you eat,so eat a healthy,well-balanced diet of low-fat foods."
3) If the acne gets really bad,then see your health care provider for a prescription for a topical antibiotic."
4) "If by bad skin you mean pimples,then wash your face regularly with soap and warm water,and keep your hair clean as well."

Question 29

Which of the following statements made by the nurse reflects the best understanding of the effect of dry skin on a client's general health and well-being?
1) "When her skin is cracked,she is so much more uncomfortable."
2) "Keeping the skin moist is so much easier than making the skin moist."
3) "She is such a proud lady;dry,cracked skin makes her feel unattractive."
4) "If I can keep her skin moisturized,it will be less likely to crack and bleed."

Question 30

The nurse notes that the elderly client she is caring for has dry,flaky skin on her hands,face,arms,and legs.The nurse knows that elderly clients may need bathing:
1) More frequently due to keeping their warmer environments
2) Less frequently than younger clients due to dry skin
3) With strong soap due to issues with incontinence
4) With very hot water and vigorous rubbing to remove dead skin cells

Question 31

The nurse should expect that which of the following clients is most likely to have difficulty performing personal hygiene tasks?
1) The 54-year-old with osteoarthritis in his upper extremity joints
2) The 26-year-old new mother experiencing postpartum depression
3) The 15-year-old client who fractured his left clavicle while skateboarding
4) The 36-year-old client who just learned that her lung cancer is inoperable

Question 32

The nurse notes that the client with diabetes mellitus that he is caring for has some edema in both lower extremities.The client also has a small open lesion on her right great toe.The nurse understands that this is a complication of diabetes mellitus and will additionally assess the client's sensation to light touch,pinprick,and temperature to determine if she has:
1) Glaucoma
2) Psoriasis
3) Neuropathy
4) Dermatitis

Question 33

On the client's admission to the hospital,the nurse notes that the client has halitosis,and when assessing the client,the nurse notes that the client has poor oral hygiene with several discolored teeth.The client shares he does not regularly brush or floss his teeth.The best reply from the nurse is:
1) "You should brush and floss regularly."
2) "Do you know that poor dental hygiene can lead to diseases beyond dental disease?"
3) "I'll get you a toothbrush and toothpaste that you can take home with you once you leave the hospital."
4) "Let me show you how to properly brush your teeth."

Question 34

The nurse is discussing skin hygiene with a group of adolescent athletes.The nurse plans to discuss the prevention and management of athlete's foot primarily because:
1) It is a common skin disorder among this particular population
2) It is both easily prevented and managed if you understand the problem
3) The condition can spread to other parts of the body if not managed well
4) The condition is often a source of social embarrassment for those who have it

Question 35

The nursing assistive personnel reports to the nurse that the client refuses to wear deodorant after the bath.The nurse's best answer to the nursing assistive personnel is:
1) "I noticed that the client really had bad body odor when I assessed her."
2) "The client is Eastern European;some social groups don't wear deodorant."
3) "Perhaps the client doesn't like our brand of deodorant."
4) "I'll try to talk with the client to get her to put on the deodorant."

Question 36

The nurse observes an adult client of Middle Eastern descent diagnosed with bipolar disorder attempting to bathe himself using only his left hand.The nurse assumes that the most likely reason for this behavior relates to:
1) A cultural preference
2) A personal idiosyncrasy
3) His psychiatric diagnosis
4) A need for personal control

Question 37

The nurse is preparing to bathe an older adult client who is expecting a visit from out of town relatives.The client expresses reluctance to bathe because he does not want to "make my sister wait to see me." Which of the following statements made by the nurse is most likely to provide the motivation to agree to the bath for this particular client?
1) "I promise to hurry;you will be done before she gets here."
2) "You don't want your sister to see you unshaved and in your pajamas."
3) "I know you've missed your sister and want to look your best for her visit."
4) "Let's get cleaned up so your sister doesn't think you aren't being well cared for."

Question 38

A client has developed several large mouth ulcers resulting from radiation treatments for oral cancer.The nurse recognizes that this condition will have its greatest immediate impact on the client's:
1) Comfort level
2) Nutritional status
3) Physical recovery
4) Emotional well-being

Question 39

Routine hygiene care can provide an opportunity for the nurse to assess the client's level of activity intolerance.Which of the following assessment questions is most likely to provide information that supports this nursing diagnosis?
1) "Will you need my help to take a bath?"
2) "Does taking a bath or shower cause you any pain?"
3) "Can you bathe and dress yourself without needing help?"
4) "Do you find yourself getting tired before you're finished bathing?"

Question 40

Which of the following interventions,regarding personal hygiene for a client who is unconscious,performed by ancillary personnel requires immediate follow-up by the RN?
1) Storing the damaged dentures in the client's bedside stand
2) Shaving the client's mustache to facilitate the nasogastric tube
3) Postponing the daily bath until the client's temperature has stabilized
4) Providing oral care with the flavored swabs provided by the client's family

Question 41

The nurse in a pediatrician's office teaches the mother of a preteen client who was treated for strep throat to do which of the following to help prevent a reoccurrence?
1) Isolate the child from the their siblings until the child has been on antibiotics for at least 24 hours.
2) Disinfect all the child's toys.
3) Wash all the child's laundry in hot bleach water.
4) Replace the child's toothbrush.

Question 42

The nurse has been preparing the diabetic client with peripheral neuropathy for discharge.Which of the following statements by the client indicates that they need additional teaching?
1) "I need to see my podiatrist to have my toenails trimmed."
2) "I will inspect my feet daily using a mirror to see all areas."
3) "I should make sure my feet are thoroughly dry after my bath."
4) "I will wear antiembolus stockings when I get home to prevent my ankles from swelling."

Question 43

Which of the following statements by the client demonstrates that they need further teaching regarding oral hygiene?
1) "I need to brush my teeth after meals."
2) "I need to floss my teeth daily."
3) "I should replace my toothbrush annually."
4) "I should a checkup every 6 months."

Question 44

The nurse is preparing a comatose client for oral hygiene.Unless contraindicated,the best position to place the client in is:
1) Sims'
2) Dorsal recumbent
3) Prone
4) Fowlers

Question 45

On assessment,the nurse discovers the dependent male client has athlete's foot bilaterally.Before delegating the bathing of the client to the nursing assistive personnel,the nurse needs to instruct the nursing assistive personnel to:
1) Use a lot of friction when washing the feet to remove the dead skin cells
2) Wash the client's feet last to avoid spreading the athlete's foot
3) Leave the feet slightly damp after washing them to prevent further drying and cracking of the skin
4) Apply the tolnaftate to the lesions on the client's feet when she is done bathing the client

Question 46

The nurse knows that she needs to provide additional teaching to the client who makes which of the following statements?
1) "I'm so glad to find out that this is only a plantar wart-I was afraid it was something contagious like athlete's foot."
2) "The health care provider will remove this plantar wart by first freezing it."
3) "I had a planter wart in the past that the health care provider removed with acid."
4) "The health care provider may remove my wart by burning it."