Quizlet Hygiene - notes PDF

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Ch. 40 Hygiene Practice Questions Study online at quizlet.com/_3tsd8g 1.

1. 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.

ANS: B No two individuals perform hygiene in the same manner; it is important to individualize the patient's care based on knowing about the patient's unique hygiene practices and preferences. Hygiene care is never routine; this care requires intimate contact with the patient and communication skills to promote the therapeutic relationship. In addition, during hygiene, the nurse should take time to learn about the patient's health promotion practices and needs, emotional needs, and health care education needs.

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

ANS: B, C If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment. Adapt your bathing procedures and the environment to reduce the triggers. For example, administer any ordered analgesic 30 minutes before a bath and be gentle in your approach. Keep the patient's body as warm as possible with warm towels and be sure the room temperature is comfortable.

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. 3.

2. 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

ANS: B Family customs play a major role during childhood in determining hygiene practices such as the frequency of bathing, the time of day bathing is performed, and even whether certain hygiene practices such as brushing of the teeth or flossing are performed. As children enter adolescence, peer groups and media often influence hygiene practices. During the adult years involvement with friends and work groups shape the expectations that people have about personal appearance. Some older adults' hygiene practices change because of changes in living conditions and available resources.

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2. 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

ANS: A, B, D A patient with peripheral neuropathy has muscle wasting of lower extremities, foot deformities, and abnormal gait. A patient with vascular insufficiency will have decreased hair growth on legs and feet, absent or decreased pulses, and thickened nails.

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3. 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.

ANS: A, B, C CHG wipes are easy to use and accessible for older patients and bariatric patients, offering a no-rinse or -drying procedure. For a bariatric patient or a patient who is diaphoretic, provide special attention to body areas such as beneath the woman's breasts, in the groin, skin folds, and perineal area, where moisture collects and irritates skin surfaces. Use wipes as directed on package—one wipe per each area of the body. CHG can leave the skin feeling sticky. If patients complain about its use, you need to explain their vulnerability to infection and how CHG helps reduce occurrence of health care-associated infection.

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. 6.

3. 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.

ANS: C The nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the same importance for some ethnic groups as it does for others.

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4. 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?

ANS: A Allow the patient to follow normal hygiene practices; change the bath to evening. Patients have individual preferences about when to perform hygiene and grooming care. Knowing the patient's personal preferences promotes individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene and trying again is not an option since the nurse already knows the reason for refusal. Adapting practices to meet individual needs is required.

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. 8.

5. 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.

ANS: D A patient's condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Apply the elements of critical thinking as you use the nursing process to meet patients' hygiene needs. Critical thinking will help you determine when foot care, daily bathing, and hygiene needs are important and when they are not.

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5. 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.

ANS: C, D, E When making an occupied bed, advise patients they will feel a lump when turning, turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves are used. Keep soiled linen away from uniform.

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7. The nurse is bathing a patient and ANS: A notices movement in the patient's hair. Which action will the nurse take? In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. If pediculosis capitis (head lice) a. is suspected, the nurse must protect self against self-infestations by handwashing and by using gloves or tongue blades to inspect the patient's hair. Suspicions cannot be ignored. Use gloves to inspect the hair. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice. Caution against use of products containing lindane because the b. ingredient is toxic and known to cause adverse reactions. Apply a lindane-based shampoo immediately. c. Shave the hair off of the patient's head. d. Ignore the movement and continue.

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8. 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.

ANS: A An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patient's eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time and cannot assume the glasses are missing. Asking the patient where the glasses are is inappropriate since the patient is unresponsive.

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

ANS: B Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is.

b. A patient who is diaphoretic c. A patient with strong pedal pulses d. A patient with adequate skin turgor 13.

10)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.

ANS: C Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Verbalization is affected when altered cognition occurs from dementia, psychological disorders, or temporary delirium, not from immobility.

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11. 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

ANS: A Patients with paralysis, circulatory insufficiency, or peripheral neuropathy (nerve damage) are unable to sense an injury to the skin (decreased pain sensation). The presence of urinary incontinence, circulatory insufficiency, and neuropathy can combine to result in breakdown, so the patient has an increased risk of skin impairment. While the patient may have decreased caloric intake, the patient will not have accelerated wound healing with circulatory insufficiency, neuropathy, and incontinence. While the patient is at high risk for skin infection, the low salivary pH level is not an issue. While the patient may have a high risk for impaired venous return from the circulatory insufficiency, there is no indication the patient has dementia.

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12. 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.

ANS: A Assess surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic devices. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues, promoting pressure ulcers. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.

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13. 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.

ANS: D During a bath, assess the status of sensory nerve function by checking for touch, pain, heat, cold, and pressure. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. A mobile patient can use bathroom facilities or a urinal and does not need a urinary catheter.

b. Limit caloric and protein intake. c. Turn the patient every 2 hours. d. Assess for pain during a bath. 17.

14. 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

ANS: C Plantar warts appear on the sole of the foot and are caused by the papillomavirus. Corns are caused by friction and pressure from ill-fitting or loose shoes. Athlete's foot (tinea pedis) is a fungal infection and can spread to other body parts. A callus is caused by local friction or pressure.

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15. 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.

ANS: C Surgical removal is necessary, depending on severity of pain and the size of the corn. Oval corn pads should be avoided because they increase pressure on the toes and reduce circulation. Warm water soaks soften corns before gentle rubbing with a callus file or pumice stone. Wider and softer shoes, especially shoes with a wider toe box, are helpful.

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. 19.

16. 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

ANS: A Athlete's foot spreads to other body parts, especially the hands. It is contagious and frequently recurs. Drying feet well after bathing and applying powder help prevent infection. It is caused by a fungus, not lice, and is treated with applications of griseofulvin, miconazole, or tolnaftate. Plantar wars are treated with salicylic acid or electrodesiccation.

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17. 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.

ANS: A Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Friction and pressure from ill-fitting or loose shoes causes keratosis (corns). It is seen mainly on or between toes, over bony prominences.

Fungi b. Friction c. Nail polish d. Nail polish remover 21.

18. 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

ANS: D Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Prevention of plantar warts and foot fungus are important but not the primary goal. Neuropathy is a degeneration of the peripheral nerves usually due to poor control of blood glucose levels; it is not a direct result of foot care.

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19. 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?

ANS: B Halitosis is the term for "bad breath." Cheilitis is the term for cracked lips. Dental caries are cavities in the teeth and could be a cause of the halitosis. Glossitis is the term for inflamed tongue.

a. Cheilitis b. Halitosis c. Glossitis d. Dental caries 23.

20. 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

ANS: C The skill of making an occupied bed can be delegated to nursing assistive personnel. Nail care, teaching foot care, and assessing aspiration risk of a patient with diabetes must be performed by the RN; these skills cannot be delegated.

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

ANS: D The oral cavity is the priority. Radiation to the head reduces salivary flow and lowers pH of saliva, leading to stomatitis and tooth decay, while chemotherapy drugs kill the normal cells lining the oral cavity, leading to ulcers and inflammation. While the feet, nail beds, and perineum are important, they are not as affected as the oral cavity with head or neck radiation and chemotherapy.

a. Feet b. Nail beds c. Perineum d. Oral cavity 25.

22. The nurse is providing oral care to an unconscious patient. Which action should the nurse take? a. Moisten the mouth using lemonglycerin sponges. b. Hold the patient's mouth open with gloved fingers. c. Use foam swabs to help remove plaque. d. Suction the oral cavity.
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