Chapter 17: Personal Hygiene and Bed Making Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is aware that normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing is known as:

a.

sebum.

b.

the epidermis.

c.

resident bacteria.

d.

the dermis.

ANS: C

Bacteria reside on the skins outer surface. Resident bacteria constitute normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing.

Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acid coating protects the epidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins. It is not alive, however, and is not considered flora. The epidermis, or outer skin layer, is the first line of defense from external injury and infection. It contains several thin layers of cells undergoing different stages of maturation. Resident bacteria live on its surface and protect it. Three primary layers make up the skin: the epidermis, the dermis, and subcutaneous tissue. The dermis lies underneath the epidermis and is not considered flora.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Resident Bacteria KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. In relation to hygiene and the acute care setting, the nurse knows that which of the following statements is true?

a.

The disposable bath is a less desirable form of bathing than the traditional basin bath.

b.

The disposable bath is a more desirable form of bathing than the traditional basin bath.

c.

The disposable bath is more desirable for patients who can bathe independently.

d.

The disposable bath is not an acceptable form of bathing in the acute care setting.

ANS: B

Prepackaged disposable bath products have been shown to decrease the spread of infection. The disposable bath is a desirable form of bathing for patients who are unable to bathe themselves in critical care and long-term care settings; it is even preferable to the traditional basin bath.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 394-395

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: The Disposable Bath KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk?

a.

Not provide oral hygiene because this may cause bacterial contamination of the airway.

b.

Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth.

c.

Not use chlorhexidine in oral care because it enhances the rate at which VAP develops.

d.

Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP.

ANS: D

Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. Presently, chlorhexidine is recommended during the postoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from the colonization of bacteria in the oral pharynx. These microorganisms then migrate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene.

DIF: Cognitive Level: Application REF: Text reference: p. 411

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Chlorhexidine KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The nurse plans to give the patient a therapeutic bath. Which of the following is considered therapeutic?

a.

Bed bath

b.

Sponge bath at the sink

c.

Sitz bath

d.

Bag bath

ANS: C

The Sitz bath cleanses and reduces pain and inflammation in perineal and anal areas. It is used for a patient who has undergone rectal or perineal surgery or childbirth or has local irritation from hemorrhoids or fissures. There are two categories of baths: cleansing and therapeutic. Cleansing baths include the bed bath, tub bath, sponge bath at the sink, shower, and bag bath.

DIF: Cognitive Level: Analysis REF: Text reference: p. 395

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Therapeutic Baths KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5. What should the nurse do before starting a patients bed bath?

a.

Lower the bed.

b.

Offer the bedpan or urinal.

c.

Partially undress the patient.

d.

Place the head of the bed in high-Fowlers position.

ANS: B

The patient will feel more comfortable after voiding, and this will prevent interruption of the bath. The bed should be raised to a comfortable working height to aid the nurses access to the patient and to minimize strain on the nurses back muscles. The patients gown or pajamas are removed and the bath blanket is used to cover the patient. This provides full exposure of body parts during bathing. The head of the bed is raised 30 to 45 degrees if the patients condition allows.

DIF: Cognitive Level: Application REF: Text reference: p. 397

OBJ: Administer a complete bed bath. TOP: Providing Comfort During the Bed Bath

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She places a bath blanket over the patient and:

a.

removes the gown from the arm with the IV first.

b.

removes the gown from the arm without the IV first.

c.

removes the gown after the bath to keep the patient warm.

d.

readjusts the IV rate before removing the gown.

ANS: B

If the patient has an IV line, remove the gown from the arm without the IV first. Then remove the gown from the arm with the IV. Remove the IV from the pole, and slide the IV container and tubing through the arm of the patients gown. Rehang the IV container; check the flow rate and regulate if necessary. Removing the patients gown or pajamas before the bath provides full exposure of body parts during bathing. Rehang the IV container after changing the gown. Check the flow rate. It may have changed with all the manipulation of the gown change. Regulate if necessary.

DIF: Cognitive Level: Application REF: Text reference: p. 398

OBJ: Administer a complete bed bath. TOP: Changing the Hospital Gown

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. While washing the patients face, the nurse should:

a.

wash the eyes using soap and warm water.

b.

wash the eyes from outer canthus to inner canthus.

c.

wash the eyes with plain warm water.

d.

use the same portion of the washcloth.

ANS: C

Wash the patients eyes with plain warm water, using a clean area of cloth for each eye, bathing from inner to outer canthus. Soap irritates eyes. Use of separate sections of the mitt reduces infection transmission. Bathing the eye gently from inner to outer canthus prevents secretions from entering the nasolacrimal duct.

DIF: Cognitive Level: Application REF: Text reference: p. 399

OBJ: Administer a complete bed bath. TOP: Washing the Eyes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. When bathing a patient, which sequence is the correct approach to use?

a.

Wash the feet after the legs.

b.

Wash the eyes after the face.

c.

Wash the legs before the abdomen.

d.

Wash the back area before the extremities.

ANS: A

When washing the patient the nurse will try to work from the most soiled area to the least soiled area. Therefore, the legs are washed before the feet, the eyes are washed before the face, the abdomen is washed before the legs, and the back is washed after the extremities.

DIF: Cognitive Level: Application REF: Text reference: pp. 399-401

OBJ: Administer a complete bed bath. TOP: Sequence of the Bed Bath

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. What should hygienic care of the patient with dry skin include?

a.

Use of moisturizers

b.

Use of ultraviolet light

c.

Application of antiseptic lotion

d.

Lowering of bath water temperature

ANS: A

Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Dry skin results in reduced pliability and cracking. Moisturizers help to prevent skin breakdown. Ultraviolet light and antiseptic lotion are not used to treat dry skin. Decreased bath water temperature causes chilling.

DIF: Cognitive Level: Application REF: Text reference: p. 401

OBJ: Administer a complete bed bath. TOP: Dry Skin

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. While giving the patient a bed bath, the nurse notices a reddened area on the patients coccyx. The nurse should:

a.

decrease the temperature of the bath water.

b.

massage the reddened area to decrease the redness.

c.

apply topical moisturizing agents to the area.

d.

ignore the redness because it will return to normal soon.

ANS: C

Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Decreased bath water temperature causes chilling. Do not massage any reddened area on the patients skin. Reddened areas, especially over bony prominences, indicate localized injury to the skin and/or underlying tissue and cannot be ignored.

DIF: Cognitive Level: Application REF: Text reference: p. 401

OBJ: Administer a complete bed bath. TOP: Reddened Areas

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. The optimal position for a female patient for the provision of perineal care is:

a.

prone.

b.

side-lying.

c.

high-Fowlers.

d.

dorsal recumbent.

ANS: D

The dorsal recumbent position provides full exposure of the female genitalia. The side-lying, prone, and high-Fowlers positions do not allow adequate exposure of the female genitalia.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 403

OBJ: Administer a complete bed bath. TOP: Perineal Care for the Female

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. While evaluating the hygienic care practices of a female patient, the nurse recognizes that additional instruction is necessary if the patient:

a.

washes the perineal area from back to front.

b.

washes the labia majora before the labia minora.

c.

avoids tension on the indwelling catheter.

d.

uses separate sections of the washcloth for each cleansing stroke.

ANS: A

The patient should wash downward from the pubic area toward the rectum in one smooth stroke. She should use a separate section of the cloth for each stroke.

DIF: Cognitive Level: Application REF: Text reference: p. 403

OBJ: Identify principles of aseptic technique applied while administering a bed bath.

TOP: Perineal Care for the Female KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. In providing perineal care for a male patient, the nurse realizes that the patient has not been circumcised. The nurse should:

a.

retract the foreskin after care has been completed.

b.

place the patient in prone position.

c.

replace the foreskin to its natural position after care has been provided.

d.

have the patient adduct his legs.

ANS: C

After administering male perineal care for uncircumcised males, make sure that the foreskin is in its natural position. This is extremely important for those patients with decreased sensation in the lower extremities. Tightening of the foreskin around the shaft of the penis causes local edema, discomfort, and, if not corrected, permanent urethral damage. Assist the patient to a supine position and have him abduct his legs.

DIF: Cognitive Level: Application REF: Text reference: p. 404

OBJ: Administer a complete bed bath. TOP: Perineal Care for the Male Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. The home care nurse is getting ready to help the patient prepare a tub bath. What should the nurse be sure to do?

a.

Instruct the patient to use safety bars.

b.

Use the patients favorite bath oil for aroma therapy.

c.

Instruct the patient to stay in the tub no longer than 30 minutes.

d.

Check on the patient every 20 minutes.

ANS: A

Instruct the patient to use safety bars when getting into and out of the tub or shower. Caution the patient against the use of bath oil in tub water. This could lead to falls. Instruct the patient not to remain in the tub longer than 20 minutes. Check on the patient every 5 minutes.

DIF: Cognitive Level: Application REF: Text reference: pp. 403-404

OBJ: Explain precautions to take when assisting patients with a tub bath or shower.

TOP: Preparing for a Tub Bath KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. When teaching parents how to provide oral care to their child, the nurse instructs them to:

a.

give bottles with juice at bedtime.

b.

begin dental visits after the child is 8 years old.

c.

allow the preschool child to floss his teeth without parental supervision.

d.

limit snacks to three or four per day.

ANS: D

Limit snacks to three or four per day. Avoid sugary snacks and drinks and sticky candy. Teach parents that the infant should not be put to bed with a bottle; this causes tooth decay as well as ear infection. Children should have their first dental examination at 1 year or sooner if needed. Then children need to have a dental examination every 6 months. Young children will need parenteral assistance and supervision to learn to floss correctly.

DIF: Cognitive Level: Application REF: Text reference: p. 409

OBJ: Identify guidelines to follow when administering oral hygiene.

TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. The nurse is about to provide oral hygiene to an unconscious patient. To do so, she places the patient in which position?

a.

Fowlers

b.

Semi-Fowlers

c.

Sims

d.

Supine

ANS: C

Unless contraindicated (e.g., head injury, neck trauma), lower the side rail and position the patient on the side (Sims position) with the head turned well toward the dependent side and the head of the bed lowered. Raise the side rail. This allows secretions to drain from the mouth instead of collecting in the back of the pharynx and prevents aspiration. This position allows secretions to drain toward the lungs as a result of gravity.

DIF: Cognitive Level: Application REF: Text reference: p. 412

OBJ: Explain differences in providing oral hygiene to dependent versus unconscious patients.

TOP: Oral Hygiene for an Unconscious Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. A nurse recognizes that a shampoo may be contraindicated for a bed-bound patient with:

a.

heart disease.

b.

diabetes mellitus.

c.

a neck injury.

d.

a bleeding disorder.

ANS: C

Caution is needed with patients who have suffered neck injuries because flexion and hyperextension of the neck could cause further injury. Heart disease does not mean that a shampoo is contraindicated. A shampoo is not contraindicated for patients with diabetes mellitus or a bleeding disorder.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 418

OBJ: Identify guidelines for administering hair, nail, and foot care.

TOP: Washing the Hair of Patients With Neck Injuries

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

18. Shaving with a disposable razor is contraindicated for a patient with:

a.

heart disease.

b.

diabetes mellitus.

c.

a head injury.

d.

a bleeding disorder.

ANS: D

Before shaving, assess whether the patient has a bleeding tendency. Review medical history or laboratory values (e.g., platelet counts, prothrombin time). Determine the need to use an electric razor for the patients safety because of the potential for bleeding. Shaving with a disposable razor is not contraindicated for patients with heart disease, diabetes mellitus, or a head injury.

DIF: Cognitive Level: Analysis REF: Text reference: p. 415|Text reference: p. 418

OBJ: Shave a male or female patient. TOP: Shaving a Male Patient

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

19. When evaluating the shaving of a patient done by a family member, the nurse determines that the technique is done appropriately when:

a.

long strokes are used.

b.

the razor is held at a 45-degree angle to the skin.

c.

shaving is done against the direction of hair growth.

d.

a cool cloth is used on the skin before the shave.

ANS: B

The razor should be held in the dominant hand at a 45-degree angle to the patients skin. Begin by shaving across one side of the patients face using short, firm strokes in the direction the hair grows. Use the nondominant hand to gently pull the skin taut while shaving. Check with the patient, and ask whether he feels comfortable. Use a warm cloth. A warm cloth helps soften the skin and beard, and the sensation of warmth can be relaxing.

DIF: Cognitive Level: Application REF: Text reference: p. 417

OBJ: Shave a male or female patient. TOP: Shaving a Male Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. The nurse is providing nail care for the patient who wants his fingernails done. The nurse should:

a.

clip the fingernails gently to prevent injury.

b.

clean under the nails using an orange stick.

c.

soak the fingernails no longer than 10 minutes.

d.

clean under the nails using the end of a cotton swab.

ANS: C

Unless the patient has diabetes, allow the patients feet and fingernails to soak no longer than 10 minutes. The goal is to soften the skin and debris beneath the nails, without causing excessive dryness. Obtain a physicians order for cutting the nails (required by most agencies). The patients skin may be cut accidentally. Certain patients are more at risk for infection, depending on their medical condition. Check agency policy for appropriate process for cleaning beneath the nails. Do not use an orange stick or the end of a cotton swab; both of these splinter and can cause injury.

DIF: Cognitive Level: Application REF: Text reference: p. 423

OBJ: Safely administer nail care. TOP: Nail Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21. The nurse assesses the patients skin and notices an abrasion. Which of the following best describes this type of skin abnormality?

a.

A papulopustular skin eruption

b.

Rough texture on the skin surface

c.

Erythema and scaly, oozing areas

d.

A scraping away of the epidermis

ANS: D

An abrasion is a scraping or rubbing away of the epidermis; it may result in localized bleeding and later weeping of serous fluid. Acne is defined as a papulopustular skin eruption. Rough texture may indicate dry skin, not an abrasion. Scaly, oozing erythematous areas may indicate contact dermatitis.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 393

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Skin Problems KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

22. The nurse is caring for a gentleman who has dry skin. When the following interventions are compared, which would be most appropriate for this patient?

a.

Limiting the frequency of bathing

b.

Using a fat-free soap for washing

c.

Using warm water and moisturizers

d.

Bathing with hot water to increase blood flow

ANS: C

Effective treatment for dry skin does not include limiting the frequency of bathing but lies in bathing with warm, not hot, water and using moisturizers. Superfatted soap (e.g., Dove) should be used for cleansing. The body should be rinsed well of all soap, because residue left can cause irritation and breakdown. Moisture should be added to the air through the use of a humidifier. Fluid intake should be increased when the skin is dry.

DIF: Cognitive Level: Application

REF: Text reference: p. 393|Text reference: p. 401|Text reference: p. 424

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Treatment for Dry Skin KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23. The patient confides in the nurse that she is bothered by the fact that she has alopecia. How should the nurse respond to this information?

a.

Shave hair off of the affected area.

b.

Use permethrin (Nix).

c.

Offer the patient access to scarves or wigs.

d.

Place a drop of oil on the area.

ANS: C

Alopecia is balding patches in the periphery of the hairline. Offer patients access to scarves, hairpieces, or wigs. Stop hair care practices that damage hair. Shaving hair off of the affected area is the treatment for pediculosis pubis (crab lice). Permethrin is the treatment for pediculosis capitis (head lice). Ticks are removed by placing a drop of oil or ether on the tick, causing it to suffocate.

DIF: Cognitive Level: Application REF: Text reference: p. 415

OBJ: Identify guidelines for administering hair, nail, and foot care.

TOP: Alopecia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

24. The patient requires postural drainage three times a day. Which of the following bed positions would be most appropriate for this task?

a.

Fowlers position

b.

Trendelenburgs position

c.

Reverse Trendelenburgs position

d.

Semi-Fowlers position

ANS: B

With Trendelenburgs position, the entire bed frame is tilted, with the head of the bed down. This position facilitates postural drainage and venous return in patients with poor peripheral perfusion. In Fowlers position, the head of the bed is raised to an angle of 45 to 90 degrees or more. This position is preferred while the patient eats, is used during nasogastric tube insertion and nasotracheal suction, and promotes lung expansion. In reverse Trendelenburgs position, the entire bed frame is tilted, with the foot of the bed down. It is used infrequently, promotes gastric emptying, and prevents esophageal reflux. In semi-Fowlers position, the head of the bed is raised approximately 30 to 45 degrees. This promotes lung expansion and relieves strain on abdominal muscles.

DIF: Cognitive Level: Application REF: Text reference: p. 427

OBJ: Identify guidelines for administering hair, nail, and foot care.

TOP: Bed Positions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The skin, the largest human body organ, protects us from heat, light, injury, and infection and does which of the following? (Select all that apply.)

a.

Helps regulate body temperature

b.

Stores water, vitamin D, and fat

c.

Helps to sense pain

d.

Prevents the entry of bacteria

ANS: A, B, C, D

Skin, the largest human body organ, protects us from heat, light, injury, and infection and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 439

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Skin KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP). Sources of VAP include: (Select all that apply.)

a.

bacteria in the oral pharynx.

b.

dental plaque.

c.

chlorhexidine rinses.

d.

frequent oral hygiene.

ANS: A, B

VAP results from the colonization of bacteria in the oral pharynx. These microorganisms then translocate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this, guidelines for oral care in ventilator patients and in those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 394|Text reference: p. 411

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Oral Hygiene KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. When taking a shower in the home setting, the patient at risk for falls may benefit from: (Select all that apply.)

a.

installation of grab bars.

b.

adhesive strips applied to the tub floor.

c.

addition of a shower chair or stool.

d.

a hydraulic lift.

ANS: A, B, C

Patients at risk for falls may benefit from the installation of grab bars in the shower, the application of adhesive strips to the shower or tub floor, and the addition of a shower chair or placement of a chair or stool. Hydraulic lifts are useful in bathtubs.

DIF: Cognitive Level: Application REF: Text reference: p. 403

OBJ: Explain precautions to take when assisting patients with a tub bath or shower.

TOP: Preparing for a Shower KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Patients at greatest risk for developing serious foot problems include those with: (Select all that apply.)

a.

peripheral neuropathy.

b.

peripheral vascular disease.

c.

pancreatitis.

d.

diabetes.

ANS: A, B, D

Patients at greatest risk for developing serious foot problems are those with peripheral neuropathy and peripheral vascular disease. These two disorders, commonly found in patients with diabetes, cause reduction in blood flow to the extremities and loss of sensory, motor, and autonomic nerve function. As a result, the patient is unable to feel heat and cold, pain, pressure, and the position of the foot. This reduction in blood flow impairs healing and promotes risk for infection.

DIF: Cognitive Level: Analysis REF: Text reference: p. 420

OBJ: Identify risk factors for foot and nail problems. TOP: Foot Problems

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. The development of diabetic foot ulcers is dependent on which of the following? (Select all that apply.)

a.

Peripheral neuropathy

b.

Tissue ischemia

c.

Trauma to the foot

d.

Pain in the affected extremity

ANS: A, B, C

The development of diabetic foot ulcers is multifactorial; three contributing factors are (1) peripheral neuropathy (changes in the function and efficiency of the nerves), (2) ischemia (decrease in blood flow related to plaque formation in the arteries), and (3) a pivotal event (e.g., trauma caused by banging the toe or stepping on a foreign object).

DIF: Cognitive Level: Comprehension REF: Text reference: p. 420

OBJ: Identify risk factors for foot and nail problems. TOP: Diabetic Foot Ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. A patient is admitted with the diagnosis of pediculosis capitis (head lice). Proper treatment for this condition would include which of the following? (Select all that apply.)

a.

Use of medicated shampoo or permethrin (Nix)

b.

Use of products containing lindane

c.

Combing the hair with a nit comb for 2 to 3 days after treatment

d.

Washing linens in cold water for 30 minutes

ANS: A, C

Use medicated shampoo available as a crme rinse for eliminating lice, or permethrin (Nix). Caution against the use of products containing lindane, because this ingredient is toxic and is known to cause adverse reactions. Remove the patients clothing before treatment, and apply new clothing after treatment. Repeat treatment according to product directions. Check the hair for nits, and comb with a nit comb for 2 to 3 days until you are sure all lice and nits have been removed. Manual removal of lice is the best option when treatment has failed. Vacuum infested areas of the home. Wash linens in hot water, and dry for at least 30 minutes.

DIF: Cognitive Level: Analysis REF: Text reference: p. 415

OBJ: Identify guidelines for administering hair, nail, and foot care.

TOP: Lice KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. The ____________ is the largest human organ.

ANS:

skin

Skin, the largest human body organ, protects us from heat, light, injury, and infection, and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Skin KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The first line of defense against external injury and infection contains several thin layers of cells undergoing different stages of maturation. This first line of defense is known as the _______.

ANS:

epidermis

The epidermis, or outer skin layer, is the first line of defense against external injury and infection. It contains several thin layers of cells undergoing different stages of maturation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: The Epidermis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. _________________ provides an acidic coating to protect the epidermis against penetration from chemicals and microorganisms; it also minimizes loss of water and plasma proteins.

ANS:

Sebum

Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acidic coating protects the epidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Sebum KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. ________________ removes sweat, oil, dirt and bacteria and helps maintain skin integrity.

ANS:

Bathing

Bathing removes sweat, oil, dirt and microorganisms and helps maintain skin integrity.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 395

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Bathing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5. The act of chewing is also known as ________________.

ANS:

mastication

The teeth are organs of chewing, or mastication.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Mastication KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. ______________ are mucous membranes with underlying supportive tissue that encircle the neck of erupted teeth to hold them in place.

ANS:

Gingivae

The gums, or gingival tissue, are mucous membranes with underlying supportive fibrous tissue. They encircle the neck of erupted teeth to hold them firmly in place. The gums normally are pink, moist, firm, and relatively inelastic.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Gingivae KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7. Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent gum inflammation known as ____________.

ANS:

gingivitis

Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent gingivitis, or gum inflammation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 392

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Gingivitis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. Tissue that surrounds the fingernail, slowly grows over the nail, and must be regularly pushed back with a soft nail brush is known as the __________________.

ANS:

cuticle

The nail is surrounded by a cuticle, which slowly grows over the nail and must be regularly pushed back with a soft nail brush. Take care to avoid breaking the skin around the nail. Breaks in the skin allow the entry of bacteria.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 394

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: The Cuticle KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

9. Many foot ulcers are due to repeat trauma over time, often caused by ________________.

ANS: poorly fitting shoes

DIF: Cognitive Level: Comprehension REF: Text reference: p. 422

OBJ: Identify risk factors for foot and nail problems. TOP: Foot Ulcers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10. ________________ is defined as excessive growth of body and facial hair.

ANS:

Hirsutism

Hirsutism is defined as excessive growth of body and facial hair, especially in women.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 393

OBJ: Discuss guidelines used to provide personal hygiene to patients.

TOP: Hirsutism KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11. _____________ is balding patches in the periphery of the hairline.

ANS:

Alopecia

Alopecia is balding patches in the periphery of the hairline. Hair becomes brittle and broken. Alopecia can be caused by diseases, as a medication side effect, or after improper use of hair care products and hair styling devices.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 415

OBJ: Identify guidelines for administering hair, nail, and foot care.

TOP: Alopecia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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