Chapter 22 Facilitating Hygiene

During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should:

a) Have him sign a permission form

b) Check to see whether the patient is taking anticoagulants

c) Tell him that only a family member may shave a patient

d) Position him flat in bed

b) Check to see whether the patient is taking anticoagulants

The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?

a) Avoid bathing the patient.

b) Use cool water for bathing.

c) Provide care in short intervals.

d) Rub briskly when towel drying.

c) Provide care in short intervals.

During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to:

a) Bathe the patient more frequently.

b) Use an emollient on the dry skin.

c) Massage the skin with warm water.

d) Discourage fluid intake.

b) Use an emollient on the dry skin.

The nurse is about to bathe a female patient who has an intravenous line, and needs to remove her gown. The nurse should:

a) Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown.

b) Cut the gown with scissors to allow the arm to be easily removed from gown.

c) Thread the bag and tubing through the gown sleeve, keeping the line intact.

d) Disconnect the tubing, thread it through the gown, and reconnect the tubing.

c) Thread the bag and tubing through the gown sleeve, keeping the line intact.

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.

a) 32-year-old admitted with a closed head injury

b) 76-year-old admitted with septic shock

c) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

d) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

c) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate?

a) Risk for Infection

b) Risk for Impaired Skin Integrity

c) Risk for Deficient Fluid Volume

d) Impaired Skin Integrity

b) Risk for Impaired Skin Integrity

When making an occupied bed, which of the following is most important for the nurse to do?

a) Keep the bed in the low position.

b) Keep the siderail raised on both sides of the bed.

c) Move back and forth between the sides of the bed when adjusting linens.

d) Use a bath blanket or sheet to maintain patient warmth and privacy.

d) Use a bath blanket or sheet to maintain patient warmth and privacy.

Which of the following interventions would be most appropriate for a patient who has an eye infection with moderate amount of discharge?

a) Using hydrogen peroxide to clean the eye

b) Wiping from the outer canthus to the inner canthus

c) Positioning the patient on the same side as the eye to be cleansed

d) Using a different wipe to cleanse each eye

d) Using a different wipe to cleanse each eye

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation?

a) Skin was softened from prolonged exposure to moisture.

b) Superficial layers of skin were absent.

c) Epidermal layer of skin was rubbed away.

d) Lesion caused by tissue compression was present.

b) Superficial layers of skin were absent.

For which patient is it most important to provide frequent perineal care? The patient:

a) With active lower gastrointestinal bleeding

b) Who has had an episode of diabetic ketoacidosis

c) Who has a circumcised penis

d) With a history of acute asthma

a) With active lower gastrointestinal bleeding

A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed?

a) Call for assistance to help the patient into the bathtub.

b) Wait for the patient to calm down, and then give him a towel bath.

c) Allow the patient to go without bathing for a day or two.

d) Ask another staff member to attempt the tub bath.

b) Wait for the patient to calm down, and then give him a towel bath.

The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include?

a) "Cleanse only those areas likely to cause odor."

b) "Provide the patient with warm water for washing his perineum."

c) "Wash the patient's back, buttocks, and perineum first."

d) "Bathe the patient from head to toe, cleanest areas first."

d) "Bathe the patient from head to toe, cleanest areas first."

Which action should the nurse take when scanning the patient's environment?
1. Check to make sure the nurse call device is within reach
2. Place the bed in the high position
3. Keep a food tray in the patient's room for later snacking
4. Allow the linens to have a few wrinkles

1. Check to make sure the nurse call device is within reach

A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient?

a) Tub bath

b) Complete bed bath

c) Towel bath

d) Bed bath

c) Towel bath

The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning?

a) "I can contract the infection by walking barefoot in the gymnasium's showers."

b) "The best way to avoid contracting the infection is to use good handwashing."

c) "Wearing unventilated shoes prevents the fungus from gaining contact with my feet."

d) "There is really no way to prevent its spread; it's highly contagious."

a) "I can contract the infection by walking barefoot in the gymnasium's showers."

Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin?

a) 99°F (37.2°C)

b) 102°F (38.9°C)

c) 103°F (39.4°C)

d) 105°F (40.6°C)

d) 105°F (40.6°C)

Bath water temperature should be 105°F (40.6°C) to prevent chilling, burning, and excess drying of the skin.

While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest?

a) Inadequate dietary intake

b) Normal aging process

c) Fungal infection

d) Excessive use of silver salts

a) Inadequate dietary intake

A patient with a history of seizures who takes phenytoin is at risk for which oral problem?

a) Dryness of the mouth

b) Bitter taste

c) Demineralization of the tooth enamel

d) Gingival hyperplasia

d) Gingival hyperplasia

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care?

a) Supine

b) Prone

c) Semi-Fowler's

d) Side-lying

d) Side-lying

After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as:

a) Pediculosis

b) Alopecia

c) Dandruff

d) Hirsutism

b) Alopecia

Alopecia is abnormal hair loss that can occur as a result of chemotherapy

Which of the following is a correct step in removing and cleaning a hearing aid?

a) Clean only the external surfaces, not the canal portion.

b) Clean the top part of the canal portion of the device.

c) Insert a wax loop or toothpick into the hearing aid itself.

d) Remove the battery before taking the hearing aid from the ear.

b) Clean the top part of the canal portion of the device.

The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient's artificial eye. What should the nurse ask the patient to do to best position him for this procedure?

a) Lean forward and rest the arms on the overbed table.

b) Sit back in the chair and tilt the head back.

c) Move to the bed and lie down.

d) Stand up and lean over the bed.

c) Move to the bed and lie down.