Potter and Perry Chapter 40 - Hygiene

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.)

A Cut nails frequently.

B Assess skin for redness, abrasions, and open areas daily.

C Soak feet in water at least 10 minutes before nail care.

D Apply lotion to feet daily.

E Clean between toes after bathing.

b, d, e

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. What is the correct order for administration of oral care?

1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.

2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to

30 degrees.

3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first.

4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.

5. Remove partial plate or dentures if present.

6. Gently brush tongue but avoid stimulating gag reflex.

1. 2, 5, 1, 3, 6, 4

2. 5, 1, 2, 3, 6, 4

3. 2, 5, 3, 1, 6, 4

4. 2, 1, 5, 3, 4, 6

1.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.)

A. Use antimicrobial toothpaste.

B. Brush teeth 4 times a day.

C. Use 0.12% chlorhexidine gluconate (CHG) oral rinses.

D. Use a soft toothbrush for oral care.

E. Avoid cleaning the gums and tongue.

a, c, d

A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use:

A. Community mouthwash.

B. Alcohol-based mouth rinse.

C. Normal saline rinses.

D. Firm toothbrush.

c

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.)

A. Oxygen saturation

B. Heart rate

C. Respirations

D. Gag reflex

E. Response to painful stimulus

c, d

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care?

A. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period.

B. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line.

C. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg.

D. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.

d

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.)

A. Prone position

B. Sims position

C. Semi-fowler's position with head to side

D. Trendelenburg position

E. Supine position

b, c

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nurse assistant to accomplish during the bath?

A. Checking distal pulses

B. Providing range-of-motion (ROM) exercises to extremities

C. Determining type of treatment for stage 1 pressure ulcer

D. Changing the dressing over an intravenous site

b

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.)

A. Use of cough drops

B. Immunosuppression

C. Radiation therapy

D. Dehydration

E. Presence of oral airway

c, d

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse?

A. Use tap water to clean soft lenses.

B. Follow recommendations of lens manufacturer when inserting the lenses.

C. Keep lenses moist or wet when not worn.

D. Use fresh solution daily when storing and disinfecting lenses.

a

A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because:

A. It promotes venous circulation.

B. It covers a larger area of the leg.

C. It completes care in a timely fashion.

D. It prevents blood clots in legs.

a

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nurse assistant to accomplish during the bath?

A. Checking distal pulses

B. Providing range-of-motion (ROM) exercises to extremities

C. Determining type of treatment for stage 1 pressure ulcer

D. Changing the dressing over an intravenous site

b

When a nurse delegates hygiene care for a male patient to a nurse assistant, the assistant to must use an electric razor to shave the patient with the following diagnosis:

A. Congestive heart failure

B. Pneumonia

C. Arthritis

D. Thrombocytopenia

d

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first?

A. A patient who just returned to the nursing unit from a diagnostic test

B. A patient who prefers a bath in the evening when his wife visits and can help him

C. A patient who is experiencing frequent incontinent diarrheal stools and urine

D. A patient who has been awake all night because of pain 8/10

c

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.)

A. Dentures do not always fit properly.

B. Most older adults have an increase in saliva secretions.

C. With aging the periodontal membrane becomes tighter and painful.

D. Many older adults are edentulous, and remaining teeth are often decayed.

E. The teeth of elderly patients are more sensitive to hot and cold.

a, d

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to:

A. Obsessive compulsive behavior.

B. Personal preferences.

C. The patient's cultural norm.

D. Controlling behaviors.

c