Chapter 38: Hygiene Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The client has a red, raised skin rash. During the bath, the priority action of the nurse is to:

a.

Assess for further inflammatory reactions

b.

Discuss the body-image problems created by the presence of the rash

c.

Wash the skin thoroughly with hot water and soap

d.

Moisturize the skin to prevent drying.

ANS: a

a. The first action the nurse should take is to assess for further inflammatory reactions to determine if they are localized or systemic.

b. Discussing body-image problems would not be the priority nursing action.

c. Skin should be washed with warm water, not hot, as it may dry the skin. All soap should be rinsed well, so not to leave residue that may cause further irritation.

d. The rash may be caused by moisture; thus moisturizing the skin would not be appropriate. A lotion to help prevent itching may be applied.

REF: Text Reference: p. 1009

2. The nurse is caring for a client who has right-sided paralysis after a CVA (stroke). Which of the following factors would be most likely to result in pressure ulcer formation for this client?

a.

Poor nutrition

b.

Immobility

c.

Reduced hydration

d.

Skin secretions

ANS: b

b. The client who has right-sided paralysis is at increased risk for a pressure ulcer developing because of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. The inability to turn or change position increases risk for pressure ulcers.

a. Poor nutrition is a risk factor for developing a pressure ulcer, but not for this client.

c. This client is not identified as having reduced hydration.

d. Skin secretions increase the risk for developing a pressure ulcer. However, this clients greatest risk factor is having impaired mobility.

REF: Text Reference: p. 1010

3. The nurse delegates the hygienic care of a male client to the nursing assistant. In reviewing the client assignment, the nurse instructs the assistant to make sure to use an electric razor to shave the client with:

a.

Thrombocytopenia

b.

Congestive heart failure

c.

Osteoarthritis

d.

Pneumonia

ANS: a

a. Clients prone to bleeding, such as the client with thrombocytopenia, must use an electric razor.

b. Clients with congestive heart failure may use a razor blade to shave.

c. Clients with osteoarthritis do not have to use an electric razor to shave.

d. Clients with pneumonia may use a razor blade to shave. If the client is wearing oxygen, an electric razor should not be used, as it could create a spark. Oxygen is flammable.

REF: Text Reference: p. 1049

4. The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would be evaluated as appropriate?

a.

Placing dentures in a tissue while not worn

b.

Cutting the clients nails with scissors

c.

Using soap to cleanse the eye orbits

d.

Washing the clients legs with long strokes from the ankle to the knee

ANS: d

d. To promote venous return, the nursing assistant should use long strokes washing the clients legs from the ankle to the knee and from the knee to thigh.

a. To prevent warping, dentures should be kept covered in water when they are not worn, and they should always be stored in an enclosed, labeled cup, with the cup placed in the clients bedside stand.

b. Clip nails with nail clippers straight across and even with tops of fingers, and then filed. Scissors should not be used.

c. The clients eyes should be washed with plain water, as soap irritates eyes.

REF: Text Reference: p. 1027

5. A 61-year-old with diabetes mellitus has physicians orders for meticulous foot care. Which of the following is the best rationale for the order?

a.

The aging process causes increased skin breakdown.

b.

Increased neuropathy occurs with this pathology and places the client at risk.

c.

The client probably has a history of poor hygienic care.

d.

The lower extremities are difficult to see and therefore hard to maintain with good hygiene.

ANS: b

b. Vascular changes associated with diabetes mellitus reduce the blood supply to the feet. Sensation in the feet also can be reduced as a result of damage to the nerves (i.e., as with diabetic neuropathy). Sensory loss in the feet may result in undetected injuries. These clients are especially at risk for the development of chronic foot ulcers.

a. The best rationale for meticulous foot care for this client is because of the risks associated with the clients diagnosis of diabetes mellitus.

c. No indication is apparent that the client has a history of poor hygienic care.

d. Poor vision may contribute to difficulty in providing foot care, but this clients greatest risk for developing a foot ulcer is diabetic neuropathy.

REF: Text Reference: p. 1038

6. The nurse is instructing the client with peripheral vascular disease about daily foot care. The nurses instruction for the client includes:

a.

Soaking the feet 5 to 10 minutes each day

b.

Filing the nails into a curve shape

c.

Using commercial corn removers if needed

d.

Applying lambs wool between the toes

ANS: d

d. Wrapping small pieces of lambs wool around toes reduces irritation of soft corns between toes.

a. Clients with peripheral vascular disease should not soak their feet. Soaking increases risk of infection because of maceration of the skin.

b. Nails should be filed straight across and square.

c. The client with peripheral vascular disease should not cut corns or calluses or use commercial removers. The client should consult a podiatrist.

REF: Text Reference: p. 1038, Text Reference: p. 1039

7. To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions?

a.

Reverse Trendelenburg

b.

High-Fowler with the head to the side

c.

Side-lying with the head turned toward the nurse

d.

Supine with the neck slightly forward

ANS: c

c. For administering oral care, the nurse should place a semi-comatose client on the side (Sims position) with head turned well toward dependent side to facilitate drainage of secretions from the mouth.

a. The semi-comatose client should not be placed in reverse Trendelenburg position for oral care.

b. The semi-comatose client should not be placed in the high-Fowler position for oral care.

c. The semi-comatose client should not be placed supine for oral care, as oral secretions would collect in the back of the pharynx.

REF: Text Reference: p. 1044

8. The client is unable to perform self-care for the hair. The nurse is aware that which of the following is accurate when performing hair care?

a.

Brushing the hair distributes the natural oils evenly.

b.

Using a hot comb may be very helpful for straight and oily hair

c.

Very tight braids keep the hair in good condition

d.

Shampooing should be done daily

ANS: a

a. Frequent brushing helps to keep hair clean and distributes oil evenly along hair shafts.

b. A hot comb would not be helpful for straight or oily hair.

c. Braids made too tightly can lead to bald patches.

d. The frequency of shampooing depends on a persons daily routines and the condition of the hair.

REF: Text Reference: p. 1046

9. A client has recently experienced difficulty hearing out of both ears. Which of the following is the best nursing response to the client?

a.

Lets irrigate your ears with cool water.

b.

Can you turn your head toward me when I am talking to you?

c.

Your hearing aid should not need a new battery for at least 3 months.

d.

Try to avoid putting a Q-Tip (cotton-tipped applicator) into your ears.

ANS: d

d. Use of cotton-tipped applicators should be avoided because they can cause earwax to become impacted within the canal.

a. Warm water, not cool, should be used to irrigate ears.

b. Asking the client to turn his or head toward the nurse is not the best response.

c. Batteries last 1 week with daily wearing of 10 to 12 hours.

REF: Text Reference: p. 1051

10. An adolescent client with acne should be taught by the nurse to:

a.

Apply moisturizing lotions or creams

b.

Wash the face and hair daily with very warm water and soap

c.

Use a depilatory to remove excess hair

d.

Add moisture to the air with the use of a humidifier

ANS: b

b. The client with acne should be taught to wash the hair and skin thoroughly each day with very warm water and soap to remove oil.

a. Moisturizing lotions or creams should not be used, as they tend to clog pores and make the acne worse.

c. It is not recommended to use a depilatory to remove excess hair.

d. Adding moisture to the air with the use of a humidifier is an appropriate intervention for the client with dry skin, not acne.

REF: Text Reference: p. 1009

11. A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of:

a.

Powerlessness

b.

Self-care deficit

c.

Tissue integrity impairment

d.

Knowledge deficit of hygiene practices

ANS: b

b. The client who is unable to complete bathing and grooming independently has a nursing diagnosis of Self-care deficit.

a. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of Powerlessness.

c. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of Tissue integrity impairment.

d. No indication is seen that this client has a Knowledge deficit of hygiene practices.

REF: Text Reference: p. 1016

12. A different approach to traditional hygienic care is the bag bath. The best rationale for using this approach is that it:

a.

Is less expensive than the traditional method

b.

Takes less time to complete

c.

Leaves the skin softer

d.

Reduces the risk of infection

ANS: d

d. The bag bath is intended to reduce the risk of infection. Use of the traditional washbasin may increase the risk of infection because if it is not cleaned and dried completely after use, gram-negative bacteria may contaminate the washbasin. Successive use of a contaminated basin may cause the clients skin to harbor more gram-negative organisms, increasing the clients risk of infection.

a. The bag bath is typically more expensive than the traditional bed-bath method.

b. Using the bag bath does take less time, but it is not the best rationale for using this method.

c. The bag bath does not leave the skin softer than traditional hygienic care.

REF: Text Reference: p. 1030

13. The nurse is preparing to assist the adult female client with perineal care. The position of choice for this client is:

a.

Dorsal recumbent

b.

Side-lying

c.

Supine

d.

Prone

ANS: a

a. To perform female perineal care, the client should be assisted to the dorsal recumbent position.

b. Side-lying is not the position of choice for performing perineal care of the female.

c. The supine position is the position of choice for performing perineal care of the male, not the female.

d. The prone position is not the position of choice for performing perineal care of the female.

REF: Text Reference: p. 1032

14. A client who is suspected of having vascular insufficiency to the lower extremities is assessed by the nurse to have a(n):

a.

Increased hair growth on the legs and feet

b.

Dull appearance of the skin

c.

Erythema on elevation of the feet

d.

Diminished pedal pulses

ANS: d

d. The client with vascular insufficiency of the lower extremities may exhibit diminished pedal pulses.

a. The client with vascular insufficiency of the lower extremities would have decreased hair growth on the legs and feet, not increased hair growth.

b. The client with vascular insufficiency typically has a shiny appearance of the skin of the lower extremities.

c. The client with vascular insufficiency characteristically demonstrates blanching of the skin on elevation.

REF: Text Reference: p. 1038

15. The nurse is completing a bed bath for a dependent adult male client. During the perineal care, the client has an erection. The nurse should:

a.

Continue with the perineal care

b.

Tell the client its okay and just to relax

c.

Ask the client to try and do the care as well as he can

d.

Defer the care until a little later in the bath

ANS: d

d. If the client has an erection during perineal care, the nurse should defer the procedure until later.

a. The nurse should not continue with the perineal care at this time.

b. Telling the client its okay may increase the clients embarrassment.

c. If the client is dependent in his care, the nurse should not ask the client to perform care he is unable to do. The nurse should maintain a professional attitude.

REF: Text Reference: p. 1033

16. A client on chemotherapy is experiencing stomatitis. The nurse advises the client to use:

a.

A commercial mouthwash

b.

An alcohol and water mixture

c.

Normal saline rinses

d.

A firm toothbrush

ANS: c

c. Normal saline rinses (approximately 30 ml) on awaking in the morning, after each meal, and at bedtime can effectively clean the oral cavity. The rinses can be increased to every 2 hours if necessary.

a. Clients with stomatitis should be advised to avoid commercial mouthwash.

b. Clients with stomatitis should be advised to avoid alcohol.

d. Gentle brushing and flossing are important in preventing bleeding of the gums. A soft toothbrush, not a firm toothbrush, should be used.

REF: Text Reference: p. 1043

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