Chapter 23- Hygiene and Self-Care Nursing School Test Banks

 

1.

A patient reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which of the following? Select all that apply.

A)

Thermal extremes

B)

Poor oral hygiene

C)

Heredity

D)

Adverse reaction to medications

E)

Bacteria

Ans:

A, B, D, E

Feedback:

The gums are made up of the oral mucosa, which covers the bone supporting the tooth; the alveolar bone, which forms sockets around the teeth; and the periodontal ligament, which joins the teeth to the bone. Inflammation in these tissues, called gingivitis or periodontitis, can be caused by local irritation from bacteria, plaque, tartar, and food impaction. Mechanical, chemical, or thermal extremes may also contribute to inflammation of the oral mucosa.

2.

The parents of three young children have discussed the dental health needs of their children with the nurse. Which of the following statements indicates the need for further instruction?

A)

Brushing is important to remove bacteria from the mouth and teeth.

B)

Tartar cannot be brushed or flossed way.

C)

Flouride treatments are needed until my children reach the age of 14.

D)

If my children do not have cavities by the age of 10, fluoride treatments can be discontinued.

Ans:

D

Feedback:

When plaque remains on the teeth, it hardens into tartar, which cannot be removed by simple brushing; a professional must scrape it off with dental instruments. Fluoride in small amounts strengthens teeth during their formation and helps prevent caries. Fluoride is added to most water-treatment systems at the appropriate concentration of 1 part per million. Adult caregivers may want to ask their dentist how to give children appropriate supplements of fluoride until the age of 14 if their water system is not fluoridated.

3.

The nurse is discussing hygiene with a group of adolescent males. A participant states he does not see the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply.

A)

Perspiration may result in fungal growth if not managed frequently.

B)

Excessive perspiration will result in potentially offensive odor

C)

Bacteria can flourish in the presence of excessive perspiration

D)

There is no medical rationale to avoid excessive perspiration

E)

Perspiration promotes skin breakdown.

Ans:

B, C, E

Feedback:

Keeping skin intact and healthy is important in preventing infection. Perspiration interacts with bacteria on the skin to cause body odor, which can be offensive, may decrease patient comfort, promote bacterial growth, and increase the likelihood of skin breakdown. Regular bathing removes excess oil, perspiration, and bacteria from the surface of the skin.

4.

The nurse is discussing hygiene with a group of adolescent males. A participant states he does not see the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply.

A)

Perspiration may result in fungal growth if not managed frequently.

B)

Excessive perspiration will result in potentially offensive odor.

C)

Bacteria can flourish in the presence of excessive perspiration.

D)

There is no medical rationale to avoid excessive perspiration.

E)

Perspiration promotes skin breakdown.

Ans:

B, C, E

Feedback:

Keeping skin intact and healthy is important in preventing infection. Perspiration interacts with bacteria on the skin to cause body odor, which can be offensive and may decrease patient comfort, promote bacterial growth, and increase the likelihood of skin breakdown. Regular bathing removes excess oil, perspiration, and bacteria from the surface of the skin.

5.

The student nurse is discussing the use of massage with the instructor. Which of the following statements by the student indicate the need for further instruction? Select all that apply.

A)

The benefits of massage may last up to 5 days.

B)

Elderly people on bed rest can benefit most from massage.

C)

The use of rubbing alcohol during a massage may be cooling.

D)

Massage has been demonstrated to promote increased restful sleep patterns.

E)

Massage may result in increased blood pressure and heart rate in a patient recovering from a stroke.

Ans:

A, B, E

Feedback:

Benefits of massage include increased comfort, relaxation, and improved sleep. In addition, research has demonstrated that the therapeutic effects of massage on patients who have had a stroke include improvements in blood pressure and heart rate. Effects have been seen to last up to 3 days after a massage. To prevent pressure ulcers, massage is no longer indicated for high-risk patients because vigorous pressure over bony prominences can damage the underlying tissue. An elderly person on bed rest would be considered at high risk for skin breakdown. People with oily skin find that alcohol is a cooling and refreshing lubricant.

6.

The nurse has provided instruction to the patient concerning the use of the sitz bath. After the instruction the nurse is evaluating the patients understanding of the teaching. Which of the following findings indicate the need for further instruction? Select all that apply.

A)

The patient uses cool water for the treatment.

B)

The patient heats the water to a temperature between 115 and 120 degrees.

C)

The patient reports that the treatment will take approximately 20 minutes.

D)

The patient explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction.

E)

The patient reports the treatment will promote circulation to the problem area.

Ans:

A, B, D

Feedback:

A sitz bath can be helpful in soaking a patients pelvic area in warm water to decrease inflammation after childbirth, rectal surgery, or to decrease the inflammation of hemorrhoids. Immersing only the pelvic region allows for application of local heat without widespread vasodilation that results when the entire body is placed in warm water. A sitz bath can be given in a special chair or tub in which the patient sits. A portable device placed in the toilet also can be used and is illustrated in Figure 23-5. <F 23-5> Warm water circulates gradually into the disposable device through tubing attached to a bag of warm water. The sitz bath usually lasts 20 minutes; the temperature of the water should be maintained at 105F to 110F, with care taken not to burn the patient.

7.

The nurse is reviewing the medication history for a newly admitted patient. The nurse correctly recognizes that xerostomia may be noted with which of the following?

A)

NSAID therapy

B)

Narcotic use

C)

Antihistamine use

D)

Antifungal medication use

Ans:

C

Feedback:

Xerostomia can be caused by many factors but is commonly a side effect of medications (diuretics, antidepressants, antiparkinsonian drugs, antihistamines, angiotensin-converting enzyme [ACE] inhibitors).

8.

The mother of a school-aged child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?

A)

It is very uncommon for a child of this age to have bedwetting issues.

B)

Did any of your other children have this problem?

C)

While this is distressing it is not completely uncommon but interventions are not normally introduced until age 6.

D)

You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening.

Ans:

C

Feedback:

Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary

9.

The nurse working in the long-term care facility correctly recognizes that most falls are related to which of the following?

A)

Toileting

B)

Confusion

C)

Polypharmacy

D)

Impaired sleep patterns

Ans:

A

Feedback:

More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal.

10.

A parent reports that her water is not fluoridated and questions the nurse whether she should start giving fluoride supplements to her 9-year-old child. Which response by the nurse is most appropriate?

A)

Fluoride supplements are not needed until your child is 13 years of age.

B)

Using a fluoride-containing toothpaste and mouthwash products eliminates the need for supplementation.

C)

In the absence of fluoridated water supplies, supplementation is recommended.

D)

Recommendations about using fluoride supplements are overrated.

Ans:

C

Feedback:

Supplements of fluoride until the age of 14 are recommended if the local water system is not fluoridated. Brushing teeth with a fluoride toothpaste twice daily, and additional fluoride measures for those at high risk, are recommended to reduce risk of dental caries in all age groups.

11.

The nurse is caring for a patient who voices concerns about the development of her 8-month-old daughter. Which of the following findings would be a source of concern?

A)

The child is unable to feed herself finger foods.

B)

The child has begun to eat some solid foods.

C)

The child is unable to hold a spoon to attempt self-feeding.

D)

The child has not been introduced to finger foods for self-feeding.

Ans:

C

Feedback:

By 3 to 4 months, infants begin to develop eyehand coordination; by 5 to 6 months many children have been introduced to solid foods. As gross motor function develops around 7 to 9 months, children can hold a spoon or drink from a cup with help. At 9 to 12 months, children can usually pick up finger food and feed themselves, and hold and drink from a bottle.

12.

The patient questions the nurse about the best manner to clean the ears. Which of the following should be included in the information provided to the patient?

A)

A toothpick wrapped in several folds of tissue

B)

A long-tip syringe to irrigate with peroxide

C)

A cotton swab and pull the pinna upward and cleanse the ear

D)

The twisted end of clean washcloth and pull auricle down

Ans:

D

Feedback:

Excessive cerumen can be removed with the twisted end of a washcloth while pulling down the auricle. Placing objects such as toothpicks or swabs in the ears may result in perforation and should be avoided. There is no need to routinely irrigate the ears.

13.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?

A)

Apply pressure over the eye with your index finger and thumb under the eye

B)

Pull up the upper lid and place your index finger under the glass edge

C)

Pull the inner canthus toward the bridge of the nose and lift under the glass

D)

Pull down on the lower lid and exert slight pressure below the lid

Ans:

D

Feedback:

To remove an artificial eye, pull down on the lower eyelid and exert slight pressure below the eyelid to overcome the suction holding the eye in place.

14.

What should the nurse do to prepare the unconscious patient for oral care? The nurse should

A)

Use small amounts of water and oral suction device

B)

Place the patient in high Fowlers position

C)

Place the patient in the supine position with head lowered

D)

Put the patient in the Fowlers position and turn head to side

Ans:

A

Feedback:

To prevent aspirations, use only small amounts of water and an oral suction device.

15.

A woman is being treated for breast cancer with 5-FU and Cisplatin in large doses. She should expect

A)

Anxiety

B)

Alopecia

C)

Dandruff

D)

Seborrhea

Ans:

B

Feedback:

Most commonly, hair loss (alopecia) is caused by cancer treatment.

16.

Which of the following medications is used to treat head lice?

A)

Keratolytic shampoo

B)

Fluoride

C)

Antiseborrhea shampoo

D)

Kwell

Ans:

D

Feedback:

The treatment choice for pediculosis corporis or pediculosis pubis is lindane (Kwell).

17.

What type of bath is preferred to decrease the inflammation after rectal surgery?

A)

Bed bath

B)

Tub bath

C)

Whirlpool bath

D)

Sitz bath

Ans:

D

Feedback:

A sitz bath can be helpful in soaking a patients pelvic area in warm water to decrease inflammation after childbirth or rectal surgery or to decrease inflammation of hemorrhoids.

18.

An elderly patient is complaining of dry, itching skin. The nurse should assess

A)

How often the patient is bathing

B)

When the patients last tub bath was

C)

What linens they are using

D)

When the severe itching occurs

Ans:

A

Feedback:

Frequent bathing for the older patient can dry skin and contribute to skin breakdown.

19.

A nurse is assisting a patient with his bed bath. The patient states, I can do it myself. The nurses best response is

A)

I really have limited time. Let me give you your bath right now.

B)

I will set up your bath for you. I will come back and help you with your back.

C)

You will need to sit up for your bath, and then I will change your bed.

D)

You will be able to take your bath by yourself tomorrow when you can get up.

Ans:

B

Feedback:

The nurse must value and support the patient becoming independent in care.

20.

When an adult patient from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should

A)

Understand that his culture may influence his hygiene and ask him his preference

B)

Ask another nurse to assist in giving the patient a complete bath every other day

C)

Give the patient a bath pan and tell him she will return when he has finished

D)

Encourage the patient to bathe daily as part of protection from infection

Ans:

A

Feedback:

Preferences for hygiene vary widely among individuals and across cultures.

21.

A 78-year-old patient with diabetes needs to have his toenails trimmed. It is important for the nurse to

A)

Remove ingrown toenails

B)

Cut the nail straight across

C)

Protect the foot from blisters

D)

Soak the foot in witch hazel

Ans:

B

Feedback:

The feet of older adults require special attention, because foot problems may relate to reduced peripheral blood flow. Poor circulation makes the feet more vulnerable to infection and skin breakdown, particularly after trauma. By cutting the nail straight across, the nurse can protect the toes from trauma.

22.

A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants. What is the best response the nurse can make?

A)

To help with potty training, the child should be placed on the toilet in the morning.

B)

The child should have fluids limited after 7:00 PM to help decrease the chance of nighttime accidents.

C)

A child her age should have control of the bladder by now, but her bowels wont be trained until next year.

D)

You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained.

Ans:

D

Feedback:

Many children achieve daytime bowel and bladder control between age 2 and 3 years. They usually stay dry through the night by 4 years.

23.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

A)

Leave the babys buttocks open to air for 2 hours each day

B)

Apply gentian violet to the buttocks with every diaper change

C)

Change diaper as soon as it is soiled and apply cornstarch

D)

Keep the diaper and buttocks clean and dry and apply zinc oxide

Ans:

D

Feedback:

Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.

24.

On the first postoperative day, the patient is assisted to the bathroom. It is important to

A)

Allow the patient privacy

B)

Assess the patients safety

C)

Assess the patients pain

D)

Allow sufficient time

Ans:

B

Feedback:

Toileting often is associated with falls; the nurse must ensure the patients safety.

25.

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: I have started buying bottled water. How will this affect my children? It is important for the nurse to educate the mothers that

A)

There is a need to determine if the bottled water has fluoride

B)

The preschool child should not drink bottled water

C)

The preschool child should only drink milk

D)

The parent should alternate bottle and tap water

Ans:

A

Feedback:

Fluoride strengthens teeth during their formation and helps prevent dental caries. Children need both milk and water. There is no reason for alternation between tap and bottled water if the bottled source has adequation flouride.

26.

When an African American adolescent patient asks the nurse how to care for her long hair, which is braided into small braids, the nurse should instruct the patient that

A)

Braids should be undone every day

B)

Combs should be washed as often as necessary

C)

Hair should be washed as often as necessary

D)

Lubricants or oils should not be used on the braids

Ans:

C

Feedback:

Shampooing removes dirt and oil from the hair and scalp. Clean hair makes patients feel good about their appearance and enhances feelings of self-worth.

27.

A patient complains of foot pain while ambulating in his shoes. The nurse assesses the patients feet and determines they are flat. The nurse should

A)

Call the patients physician and report the pain

B)

Inform the patient to walk barefoot while in the home

C)

Instruct the patient to have his feet measured to determine size

D)

Instruct the patient to make an appointment with a podiatrist

Ans:

C

Feedback:

Shoes should accommodate the size and shape of the foot and should be large enough so that the toenails do not rub on the shoes, causing skin breakdown or ingrown nails.

28.

When the nurse observes slight bruising on the patients left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for

A)

Assessment of tissues

B)

Increasing circulation

C)

Promotion of conversation

D)

Relaxation of muscles

Ans:

A

Feedback:

Bathing promotes assessment of the patients physical condition by noting injured areas, bruises, rashes, or any other unusual signs.

29.

When the nurse cleanses the patients leg during a bed bath, it will allow for

A)

Assessment of pain

B)

Increased circulation

C)

Decreased restless leg syndrome

D)

Promotion of social interaction

Ans:

B

Feedback:

Bathing increases circulation and helps maintain muscle tone and joint mobility.

30.

The first line of defense against microorganisms and infection entering the body is the persons

A)

Gastrointestinal tract

B)

Mucous membranes

C)

Hair

D)

Skin

Ans:

D

Feedback:

The skin is the first line of defense against microorganisms entering the body.

31.

The ability to bathe and perform normal grooming functions, and to dress, feed, and toilet oneself is

A)

Hygiene

B)

Activity

C)

Caring

D)

Health

Ans:

C

Feedback:

Caring related to hygiene is the ability to bathe and perform normal grooming functions and to dress, feed, and toilet oneself.

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