Chapter 39: Hygiene Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

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

1.

Assess for further inflammatory reactions

2.

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

3.

Wash the skin thoroughly with hot water and soap

4.

Moisturize the skin to prevent drying

ANS: 1

The first action the nurse should take is to assess for further inflammatory reactions to determine if it is localized or systemic. Discussing body image problems would not be the priority nursing action. 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. The rash may be caused by moisture; thus moisturizing the skin would not be appropriate. A lotion to help prevent itching may be applied.

DIF: C REF: 855 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Poor nutrition

2.

Immobility

3.

Reduced hydration

4.

Skin secretions

ANS: 2

The client, who has right-sided paralysis, is at increased risk for developing a pressure ulcer because of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. Also, the inability to turn or change position increases risk for pressure ulcers. Poor nutrition is a risk factor for developing a pressure ulcer but not for this client. This client is not identified as having reduced hydration. Skin secretions increase the risk for developing a pressure ulcer. However, this clients greatest risk factor is having impaired mobility.

DIF: A REF: 855 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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:

1.

Thrombocytopenia

2.

Congestive heart failure

3.

Osteoarthritis

4.

Pneumonia

ANS: 1

Clients prone to bleeding, such as the client with thrombocytopenia, must use an electric razor. Clients with congestive heart failure may use a razor blade to shave. Clients with osteoarthritis do not have to use an electric razor to shave. 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

DIF: C REF: 893 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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?

1.

Placing dentures in a tissue while not worn

2.

Cutting the clients nails with scissors

3.

Using soap to cleanse the eye orbits

4.

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

ANS: 4

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 the thigh. 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. Nails should be clipped with nail clippers, straight across and even with tops of fingers, then filed. Scissors should not be used. The clients eyes should be washed with plain water as soap irritates eyes.

DIF: C REF: 873 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

The aging process causes increased skin breakdown.

2.

There is increased neuropathy with this pathology that places the client at risk.

3.

The client probably has a history of poor hygienic care.

4.

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

ANS: 2

Vascular changes associated with diabetes mellitus reduce the blood supply to the feet. Sensation in the feet can also 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. The best rationale for meticulous foot care for this client is because of the risks associated with the clients diagnosis of diabetes mellitus. There is no indication the client has a history of poor hygienic care. Poor vision may contribute to difficulty in providing foot care, but this clients greatest risk for developing a foot ulcer is diabetic neuropathy.

DIF: C REF: 853 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

6. The client is unable to rest even after medication. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use when finishing the backrub?

1.

Long, firm strokes down the back

2.

Light strokes while moving up the back in a circular motion

3.

Kneading movements toward the sacrum

4.

Circular motion upward from buttocks to shoulders

ANS: 1

The nurse should end the backrub with long, firm strokes down the back. The backrub is not finished with light strokes while moving up the back in a circular motion. Kneading movements toward the sacrum are done before ending the backrub with long, firm strokes down the back. The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders.

DIF: A REF: 868 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Soaking the feet 5 to 10 minutes each day

2.

Filing the nails into a curve shape

3.

Using commercial corn removers if needed

4.

Applying lambs wool between the toes

ANS: 4

Wrapping small pieces of lambs wool around toes reduces irritation of soft corns between toes. Clients with peripheral vascular disease should not soak their feet. Soaking increases risk of infection caused by maceration of the skin. Nails should be filed straight across and square. The client with peripheral vascular disease should not cut corns or calluses or use commercial removers. The client should consult a podiatrist.

DIF: C REF: 883 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Reverse Trendelenburg

2.

High Fowlers with the head to the side

3.

Side-lying with the head turned toward the nurse

4.

Supine with the neck slightly forward

ANS: 3

For administering oral care, the nurse should place a semicomatose client on the side (Sims position) with the head turned well toward the dependent side to facilitate drainage of secretions from the mouth. The semicomatose client should not be placed in reverse Trendelenburg position for oral care. The semicomatose client should not be placed in the high-Fowlers position for oral care. The semicomatose client should not be placed supine for oral care, as oral secretions would collect in the back of the pharynx.

DIF: C REF: 888 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

9. 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?

1.

Brushing the hair distributes the natural oils evenly.

2.

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

3.

Very tight braids keep the hair in good condition.

4.

Shampooing should be done daily.

ANS: 1

Frequent brushing helps to keep hair clean and distributes oil evenly along hair shafts. A hot comb would not be helpful for straight or oily hair. Braids made too tightly can lead to bald patches. The frequency of shampooing depends on a persons daily routines and the condition of the hair.

DIF: C REF: 890 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Lets irrigate your ears with cool water.

2.

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

3.

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

4.

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

ANS: 4

Use of cotton-tipped applicators should be avoided because they can cause ear wax to become impacted within the canal. Warm water should be used to irrigate ears, not cool. Asking the client to turn his or head toward the nurse is not the best response. Batteries last 1 week with daily wearing of 10 to 12 hours.

DIF: C REF: 895 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Apply moisturizing lotions or creams

2.

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

3.

Use a depilatory to remove excess hair

4.

Add moisture to the air with the use of a humidifier

ANS: 2

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. Moisturizing lotions or creams should not be used, as they tend to clog pores and make the acne worse. It is not recommended to use a depilatory to remove excess hair. Adding moisture to the air with the use of a humidifier is an appropriate intervention for the client with dry skin, not acne.

DIF: A REF: 885 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

12. 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:

1.

Powerlessness

2.

Self-care deficit

3.

Tissue integrity impairment

4.

Knowledge deficit of hygiene practices

ANS: 2

The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.

DIF: A REF: 862 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Less expensive than the traditional method

2.

Takes less time to complete

3.

Leaves the skin softer

4.

Reduces the risk of infection

ANS: 4

The bag bath is intended to reduce the risk of infection. Use of the traditional wash basin may increase the risk of infection, because if it is not cleaned and dried completely after use, gram-negative bacteria may contaminate the wash basin. Successive use of a contaminated basin may cause the clients skin to harbor more gram-negative organisms, increasing the clients risk of infection. The bag bath is typically more expensive than the traditional bed bath method. Using the bag bath does take less time, but it is not the best rationale for using this method. The bag bath does not leave the skin softer than traditional hygienic care.

DIF: A REF: 868 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Dorsal recumbent

2.

Side-lying

3.

Supine

4.

Prone

ANS: 1

To perform female perineal care, the client should be assisted to the dorsal recumbent position. Side-lying is not the position of choice for performing perineal care of the female client. The supine position is the position of choice for performing perineal care of the male client, not the female. The prone position is not the position of choice for performing perineal care of the female client.

DIF: A REF: 868 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

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

1.

Increased hair growth on the legs and feet

2.

Dull appearance of the skin

3.

Erythema upon elevation of the feet

4.

Diminished pedal pulses

ANS: 4

The client with vascular insufficiency of the lower extremities may exhibit diminished pedal pulses. The client with vascular insufficiency of the lower extremities would have decreased hair growth on the legs and feet, not increased hair growth. The client with vascular insufficiency typically has a shiny appearance of the skin of the lower extremities. The client with vascular insufficiency characteristically demonstrates blanching of the skin on elevation.

DIF: A REF: 883 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

16. 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:

1.

Continue with the perineal care

2.

Tell the client its okay and just to relax

3.

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

4.

Defer the care until a little later in the bath

ANS: 4

If the client has an erection during perineal care, the nurse should defer the procedure until later. The nurse should not continue with the perineal care at this time. Telling the client its okay may increase the clients embarrassment. 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.

DIF: C REF: 879 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

17. A client receiving chemotherapy is experiencing stomatitis. The nurse advises the client to use:

1.

A commercial mouthwash

2.

An alcohol and water mixture

3.

Normal saline rinses

4.

A firm toothbrush

ANS: 3

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. Clients with stomatitis should be advised to avoid commercial mouthwash. Clients with stomatitis should be advised to avoid alcohol. Gentle brushing and flossing are important in preventing bleeding of the gums. A soft toothbrush, not a firm toothbrush, should be used.

DIF: A REF: 885 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

18. The nurse has delegated the task of bathing a semicomatose client to ancillary personnel. The nurse suggests that the personnel multitask while completing the bath. Which of the following would be the most appropriate intervention for the ancillary personnel to accomplish while bathing this particular client?

1.

Oral hygiene care

2.

Moisturizing hands and feet

3.

Passive range of motion exercises

4.

Care of the clients intravenous site

ANS: 3

You can integrate other nursing activities during hygiene care, including client assessment and interventions such as range-of-motion (ROM) exercises, application of dressings, or inspection and care of intravenous sites. While oral hygiene and moisturizing are done generally for all clients, ROM is particularly appropriate for this client. Care of an IV site is not a delegable task.

DIF: C REF: 863 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

19. Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?

1.

I work with my ancillary staff to be able to determine what is abnormal.

2.

The skin is easy to observe for abnormalities when you are giving the bath.

3.

I use the time to really look at my clients and determine whats normal and whats not.

4.

Bath time is an excellent time to get to know your clients and form that nurse-client relationship.

ANS: 3

Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question.

DIF: C REF: 869 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

20. Which of the following statements best reflects the nurses knowledge of the affect of skin integrity on a clients general state of health?

1.

When I keep the skin healthy, the client is healthy.

2.

If the skin isnt in good shape, illness isnt far away.

3.

I believe cleanliness is a top priority for comfort and health.

4.

If a client is able to do their own hygiene care, they feel in control.

ANS: 2

The skin protects against water loss and injury and prevents entry of disease-producing microorganisms. While all the options are correct, this answer provides the most direct statement regarding the connection with a clients state of health.

DIF: C REF: 854 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

21. The nurse best displays an understanding of the role the skin plays in monitoring the body systems and their ability to function properly when documenting which of the following regarding a 70-year-old client?

1.

Skin appears generally jaundiced.

2.

Dryness noted on heels and elbows bilaterally.

3.

Skin tears present on upper left and right arms.

4.

Skin on the hands and feet is slightly cool to the touch.

ANS: 1

The skin often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature, and hydration. The observation of the skins jaundice appearance reflects possible liver pathology. While the remaining options are appropriately related to abnormal skin, they are of less importance and/or seen in the older adult.

DIF: C REF: 855 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

22. Which of the following statements made by the nurse reflects the best understanding of the effect of dry skin on a clients general health and well-being?

1.

When her skin is cracked, she is so much more uncomfortable.

2.

Keeping the skin moist is so much easier than making the skin moist.

3.

She is such a proud lady; dry, cracked skin makes her feel unattractive.

4.

If I can keep her skin moisturized, it will be less likely to crack and bleed.

ANS: 4

Excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to enter, thus resulting in possible infection. While all of the options are correct, the answer reflects a better overall understanding of the effect of skin health on general client health.

DIF: C REF: 855 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

23. Which of the following statements made by ancillary personnel regarding the bathing of a 79-year-old client requires immediate follow-up by the nurse?

1.

At times you have to really work at getting her to agree to having a bath.

2.

I learned that an evening bath is what she is used to, so Ill bathe her before bed.

3.

She seemed to enjoy her morning bath; Ill bathe her again this evening after dinner.

4.

She really enjoys that mildly scented vanilla soap her daughter brought her yesterday.

ANS: 3

Bathing removes excess body secretions, although if excessive, it causes dry skin. The use of heavily scented soaps is often discouraged. The remaining options do not require follow-up.

DIF: C REF: 855 OBJ: Analysis

TOP: Nursing Process: Comprehension

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

24. The nurse should expect that which of the following clients is most likely to have difficulty performing personal hygiene tasks?

1.

The 54-year-old with osteoarthritis in his upper extremity joints

2.

The 26-year-old new mother experiencing postpartum depression

3.

The 15-year-old client who fractured his left clavicle while skateboarding

4.

The 36-year-old client who just learned that her lung cancer is inoperable

ANS: 1

Any condition that interferes with movement of the hand (e.g., superficial or deep pain or joint inflammation) impairs a clients self-help abilities. While the other options represent clients who may experience difficulty, the client in Option 1 will most likely not be self-sufficient with hygiene.

DIF: C REF: 860 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

25. A client has developed several large mouth ulcers resulting from radiation treatments for oral cancer. The nurse recognizes that this condition will have its greatest immediate impact on the clients:

1.

Comfort level

2.

Nutritional status

3.

Physical recovery

4.

Emotional well-being

ANS: 2

Difficulty with chewing and swallowing develops when surrounding gum tissues become inflamed or infected. The presence of these ulcerations will present immediate issues with nutritional and fluid intake. While the remaining options are not incorrect, the greatest problem is nutritional and fluid oriented.

DIF: C REF: 851 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

26. The nurse is preparing to bathe an older adult client who is expecting a visit from out of town relatives. The client expresses reluctance to bathe because he does not want to make my sister wait to see me. Which of the following statements made by the nurse is most likely to provide the motivation to agree to the bath for this particular client?

1.

I promise to hurry; you will be done before she gets here.

2.

You dont want your sister to see you unshaved and in your pajamas.

3.

I know youve missed your sister and want to look your best for her visit.

4.

Lets get cleaned up so your sister doesnt think you arent being well cared for.

ANS: 3

Motivation is a key factor in the importance of hygiene. Wanting to be acceptably bathed and dressed for the visit is the most likely motivation.

DIF: C REF: 853 OBJ: Assessment

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

27. Which of the following assessment questions is most likely to determine the reason an older adult client refuses to remove and brush his dentures?

1.

Why are you being difficult about cleaning your dentures?

2.

Will you allow me to clean your denture if you dont want too?

3.

Are you concerned about damaging your dentures if you take them out?

4.

Do you realize the problems that can occur when your dentures arent clean?

ANS: 4

It is important to know if a client perceives being at risk. For example, does the client perceive being at risk for dental disease, that dental disease is serious, and that brushing and flossing are effective in reducing risk? When clients recognize there is a risk and that they can take reasonable action with no negative consequence, they are more likely to be receptive to the nurses counseling and teaching efforts.

DIF: C REF: 853 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

28. Which of the following interventions, regarding personal hygiene for a client who is unconscious, performed by ancillary personnel requires immediate follow-up by the RN?

1.

Storing the damaged dentures in the clients bedside stand

2.

Shaving the clients mustache to facilitate the nasogastric tube

3.

Postponing the daily bath until the clients temperature has stabilized

4.

Providing oral care with the flavored swabs provided by the clients family

ANS: 2

Do not cut or shave hair without discussion with the client or family. This would need to be a nursing decision, although it is not necessarily required in this situation. The remaining options are not incorrect and so do not need follow-up.

DIF: C REF: 893 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

29. The nurse observes an adult client of Middle Eastern descent diagnosed with bipolar disorder attempting to bathe himself using only his left hand. The nurse assumes that the most likely reason for this behavior relates to:

1.

A cultural preference

2.

A personal idiosyncrasy

3.

His psychiatric diagnosis

4.

A need for personal control

ANS: 1

Among Hindus and Muslims the left hand is used for cleaning, whereas the right hand is used for eating and praying.

DIF: C REF: 860 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

30. Routine hygiene care can provide an opportunity for the nurse to assess the clients level of activity intolerance. Which of the following assessment questions is most likely to provide information that supports this nursing diagnosis?

1.

Will you need my help to take a bath?

2.

Does taking a bath or shower cause you any pain?

3.

Can you bathe and dress yourself without needing help?

4.

Do you find yourself getting tired before youre finished bathing?

ANS: 4

The remaining options are not as directed towards activity intolerance since a positive response to any of them may be a result of causes other than weakness.

DIF: C REF: 863 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

31. The nurse is discussing skin care with a group of early teens (ages 13 to 15). Which of the following is the most therapeutic response to the question, How can I keep from getting bad skin?

1.

Bad skin is a part of being a teenager; but dont make it worse with poor hygiene habits.

2.

Bad skin is often affected by what you eat, so eat a healthy, well-balanced diet of low-fat foods.

3.

If the acne gets really bad, then see your health care provider for a prescription for a topical antibiotic.

4.

If by bad skin you mean pimples, then wash your face regularly with soap and warm water, and keep your hair clean as well.

ANS: 4

Wash hair and skin thoroughly each day with warm water and soap to remove oil. The remaining options are not incorrect, but they are not addressing the primary problem.

DIF: C REF: 855 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

32. A client with darkly pigmented skin reports that the intravenous site is uncomfortable. To thoroughly assess the complaint of this particular client, the nurse should:

1.

Determine when the angiocatheter was inserted

2.

Ask the client if the area appears reddened

3.

Take an axillary temperature on the same side as the IV site

4.

Use the back of the hand to assess skin temperature at the site

ANS: 4

Using the back of the hand to detect warmth helps in the assessment for inflammation when redness is not easily observed. It is the most reliable method among the options provided.

DIF: C REF: 856 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

33. The nurse is discussing skin hygiene with a group of adolescent athletes. The nurse plans to discuss the prevention and management of athletes foot primarily because:

1.

It is a common skin disorder among this particular population

2.

It is both easily prevented and managed if you understand the problem

3.

The condition can spread to other parts of the body if not managed well

4.

The condition is often a source of social embarrassment for those who have it

ANS: 3

Athletes foot spreads to other body parts, especially hands. It is contagious and frequently recurs. While the other options are correct, they do not discuss the primary concern regarding the condition.

DIF: C REF: 857 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

34. The nurse is discussing nail care with a group of teenage girls. Which of the following statements made by one girl in the audience requires immediate follow-up by the nurse?

1.

My mother tells me that toe rings will cause me to develop calluses.

2.

Its expensive buying new shoes just because your feet keep growing.

3.

I throw my sneakers into the washing machine regularly to keep the inside surfaces clean.

4.

I cut the discolored nails on both of my great toes really short to make them a little less noticeable.

ANS: 4

Ingrown nails often result from improper nail trimming. The remaining options are correct and do not require follow-up

DIF: C REF: 857 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

35. The nurse is discussing hygiene issues with a group of mothers with young school-age children. When discussing the topic of head lice (pediculosis capitis), the nurse realizes that the most important motivation for preventing and/or managing this condition is that:

1.

The lice may carry various other serious diseases

2.

The parasites are extremely difficult to remove and kill

3.

The presence of lice typically reflects poor hygiene practices

4.

The parasites are easily transferable from one person to another

ANS: 4

Head lice are difficult to remove, and they spread to furniture. The primary problem is that other people can be easily infested if the condition is not properly treated. The remaining options are not necessarily true.

DIF: C REF: 858 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

36. The nursing assistive personnel reports to the nurse that the client refuses to wear deodorant after the bath. The nurses best answer to the nursing assistive personnel is:

1.

I noticed that the client really had bad body odor when I assessed her.

2.

The client is Eastern European; some social groups dont wear deodorant.

3.

Perhaps the client doesnt like our brand of deodorant.

4.

Ill try to talk with the client to get her to put on the deodorant.

ANS: 2

Some social groups do not wear deodorant or cosmetics. The nurse should not be judgmental regarding hygiene practices of different cultures. Answer 3 could be the issue, but the client did not ask the nursing assistive personnel if there were other types of deodorants that they could choose from. There is no need for the client to be coerced to put on deodorant, but is a personal choice that should be respected.

DIF: A REF: 858 OBJ: Knowledge

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

37. On the clients admission to the hospital, the nurse notes that the client has halitosis, and when assessing the client, the nurse notes that the client has poor oral hygiene with several discolored teeth. The client shares he does not regularly brush or floss his teeth. The best reply from the nurse is:

1.

You should brush and floss regularly.

2.

Do you know that poor dental hygiene can lead to diseases beyond dental disease?

3.

Ill get you a toothbrush and toothpaste that you can take home with you once you leave the hospital.

4.

Let me show you how to properly brush your teeth.

ANS: 2

Answer 2 provides the client with information regarding why it is important to him to brush and floss regularly. Answer 1 is a true statement, but the client probably knows that he should brush and floss regularly; the nurse can go from there and explain why he should. Although Answer 3 gives the client the equipment he needs, it does not provide him with any motivation to follow through. It is good for the nurse to demonstrate the skill of brushing and flossing, but that may not increase compliance by the client.

DIF: A REF: 853 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

38. The nurse notes that the elderly client she is caring for has dry, flaky skin on her hands, face, arms, and legs. The nurse knows that elderly clients may need bathing:

1.

More frequently due to keeping their warmer environments

2.

Less frequently than younger clients due to dry skin

3.

With strong soap due to issues with incontinence

4.

With very hot water and vigorous rubbing to remove dead skin cells

ANS: 2

The elderly may bathe less frequently and rinse body of all soap because residue left on skin can cause irritation and breakdown. The elderly frequently have their environments warm due to poor circulation. They dont necessarily perspire any more than do younger age-groups. They should bathe with mild soap and use lots of moisturizer to prevent the skin from further drying. Hot water depletes the skin of natural oils, drying it out. Vigorous rubbing can damage the skin.

DIF: B REF: 853 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

39. The nurse notes that the client with diabetes mellitus that he is caring for has some edema in both lower extremities. The client also has a small open lesion on her right great toe. The nurse understands that this is a complication of diabetes mellitus and will additionally assess the clients sensation to light touch, pinprick, and temperature to determine if she has:

1.

Glaucoma

2.

Psoriasis

3.

Neuropathy

4.

Dermatitis

ANS: 3

Palpation of the dorsalis pedis and posterior tibial pulses indicates whether adequate blood flow is reaching peripheral tissues. Edema and changes in skin color, texture, and temperature indicate if the client requires special hygienic care. Also check persons with diabetes mellitus for neuropathy, degeneration of the peripheral nerves characterized by a loss of sensation. Assess the clients sensation to light touch, pinprick, and temperature. Glaucoma is diagnosed by an eye examination that measures intraocular pressure. Psoriasis and dermatitis are both skin conditions.

DIF: A REF: 884 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

40. On examining a clients fingernails, the nurse notes that they are excessively dry. The nurse knows that this can be caused by which of the following?

1.

Fungal nail infections

2.

Dry climates

3.

Washing dishes by hand

4.

Polishing nails, and using polish remover

ANS: 4

Ask women whether they frequently polish their nails and use polish remover, because chemicals in these products cause excessive nail dryness. Inflammatory lesions and fungus of the nail bed cause thickened, horny nails, which separate from the nail bed. Dry climates and washing dishes do not cause excessively dry nails

DIF: A REF: 867 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

41. The nurse knows that she needs to provide additional teaching to the client who makes which of the following statements?

1.

Im so glad to find out that this is only a plantar wartI was afraid it was something contagious like athletes foot.

2.

The health care provider will remove this plantar wart by first freezing it.

3.

I had a planter wart in the past that the health care provider removed with acid.

4.

The health care provider may remove my wart by burning it.

ANS: 1

Plantar warts are caused by a papilloma virus and can be spread. Answers 2, 3, and 4 are all methods by which plantar warts can be removed.

DIF: A REF: 856 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

42. On assessment, the nurse discovers the dependent male client has athletes foot bilaterally. Before delegating the bathing of the client to the nursing assistive personnel, the nurse needs to instruct the nursing assistive personnel to:

1.

Use a lot of friction when washing the feet to remove the dead skin cells

2.

Wash the clients feet last to avoid spreading the athletes foot

3.

Leave the feet slightly damp after washing them to prevent further drying and cracking of the skin

4.

Apply the tolnaftate to the lesions on the clients feet when she is done bathing the client

ANS: 2

Athletes foot can be spread to other areas of the body, so the affected areas should be bathed last to avoid cross-contamination. Excessive friction may irritate the skin and cause discomfort and further skin breakdown to the client. The skin needs to be kept dry to help prevent infection. The nurse cannot delegate the application of medication to nursing assistive personnel.

DIF: A REF: 856 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

43. The nurse has been preparing the diabetic client with peripheral neuropathy for discharge. Which of the following statements by the client indicates that they need additional teaching?

1.

I need to see my podiatrist to have my toenails trimmed.

2.

I will inspect my feet daily using a mirror to see all areas.

3.

I should make sure my feet are thoroughly dry after my bath.

4.

I will wear antiembolus stockings when I get home to prevent my ankles from swelling.

ANS: 4

Restrictive stockings should not be worn in order to decrease the risk of impeding circulation to the lower extremities. Clients with neuropathy is at risk for injury to their feet because of impaired sensation. By examining all areas of the feet daily, the client can identify potential problems early. Thoroughly drying the feet minimizes risk for fungal infections and skin breakdown.

DIF: A REF: 857 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

44. The nurse in a pediatricians office teaches the mother of a preteen client who was treated for strep throat to do which of the following to help prevent a reoccurrence?

1.

Isolate the child from the their siblings until the child has been on antibiotics for at least 24 hours.

2.

Disinfect all the childs toys.

3.

Wash all the childs laundry in hot bleach water.

4.

Replace the childs toothbrush.

ANS: 4

Replacing the childs toothbrush will help prevent reinfecting the child with streptococcal bacteria.

DIF: A REF: 857 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

45. Which of the following statements by the client demonstrates that they need further teaching regarding oral hygiene?

1.

I need to brush my teeth after meals.

2.

I need to floss my teeth daily.

3.

I should replace my toothbrush annually.

4.

I should a checkup every 6 months.

ANS: 3

Toothbrushes should be replaced every 3 months, or more often if the client has an oral infection such as strep throat. Answers 1, 2, and 4 all demonstrate appropriate information.

DIF: A REF: 856 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

46. The nurse is preparing a comatose client for oral hygiene. Unless contraindicated, the best position to place the client in is:

1.

Sims

2.

Dorsal recumbent

3.

Prone

4.

Fowlers

ANS: 1

Turning the clients head to the side allows secretions to drain from mouth instead of collecting in back of pharynx, preventing aspiration. Moving the client close to the side of the bed facilitates proper body mechanics during the skill.

DIF: B REF: 885 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

MULTIPLE RESPONSE

1. Which of the following is likely to result in damage to the clients skin? (Select all that apply.)

1.

Dry shaving a client in preparation for discharge

2.

Removing the tape when discontinuing a heparin lock

3.

Frequently positioning the client on her favorite right side

4.

Applying moisturizing lotion on the heels of a diabetic client

5.

Elevating the bed to 85 degrees so the client can easily watch a movie on TV

6.

Waiting until the mechanical lift is available to transfer an immobile client

ANS: 1, 2, 3, 5

Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of dry razors, tape removal, or improper turning or positioning techniques). The remaining options are not likely to cause skin damage

DIF: C REF: 885 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

2. The nurse is assisting an older adult client with morning care. The client experienced a stroke 2 years ago and has right-sided weakness. The nurse should expect the client to require assistance with which of the following tasks? (Select all that apply.)

1.

Combing her hair

2.

Holding her toothbrush

3.

Wringing out the washcloth

4.

Rinsing with mouthwash

5.

Removing her wristwatch

6.

Wiping her face and neck

ANS: 1, 2, 3, 5

A weakened grasp resulting from arthritis, stroke, or muscular disorders prevents a client from using a toothbrush and comb and wringing out a washcloth. Any activity that requires strength and coordination may present a problem. Wiping her face and rinsing her mouth should not be problematic.

DIF: C REF: 889 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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