Chapter 39: Hygiene Nursing School Test Banks

Test Bank

MULTIPLE CHOICE

1. A number of factors influence a patients personal preferences for hygiene. Because of this, it is important for the nurse to realize that..

a.

No two individuals perform hygiene in the same manner.

b.

It is important to standardize a patients hygienic practices.

c.

Hygiene care is always routine and expected.

d.

Hygiene is not the time to learn about patient needs.

ANS: A

No two individuals perform hygiene in the same manner; it is important to individualize the patients care based on knowing about the patients unique hygiene practices and preferences. Hygiene care is never routine; this care requires intimate contact with the patient and communication skills to promote the therapeutic relationship. In addition, during hygiene, the nurse should take time to learn about the patients health promotion practices and needs, emotional needs, and health care education needs.

DIF: Remember REF: 770

OBJ: Describe factors that influence personal hygiene practices.

TOP: Assessment MSC: Caring

2. Social groups influence hygiene preferences and practices, including the type of hygienic products used and the nature and frequency of personal care. Which of the following developmental stages is most likely to be influenced by family customs?

a.

Adolescent

b.

Toddler

c.

Adult

d.

Older adult

ANS: B

During childhood, family customs influence hygiene. As children enter their adolescent years, peer group behavior often influences personal hygiene. During the adult years, involvement with friends and work groups shapes the expectations people have about their personal appearance. Some older adults hygiene practices change because of living conditions and available resources.

DIF: Analyze REF: 770

OBJ: Describe factors that influence personal hygiene practices.

TOP: Assessment MSC: Caring

3. The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, the nurse understands that

a.

Personal preferences determine hygiene practices and are unchangeable.

b.

Patients who appear unkempt place little importance on hygiene practices.

c.

The patients illness may require teaching of new hygiene practices.

d.

All cultures value cleanliness with the same degree of importance.

ANS: C

Each patient has individual desires and preferences about when to bathe, shave, and perform hair care. However, they are not unchangeable. In addition, the nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the same importance for some ethnic groups as it does for others.

DIF: Understand REF: 770

OBJ: Describe factors that influence personal hygiene practices.

TOP: Assessment MSC: Caring

4. The nurse is caring for a patient who refuses AM care. When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should

a.

Defer the bath until evening and pass on the information to the next shift.

b.

Tell the patient that she must bathe because that is the normal routine.

c.

Explain to the patient the importance of maintaining morning hygiene practices.

d.

Cancel hygiene for the day and attempt again in the morning.

ANS: A

Each patient has individual desires and preferences about when to bathe, shave, and perform hair care. Knowing the patients personal preferences assists the nurse in providing individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene is not an option. Adapting practices to meet individual needs is required. No evidence demonstrates greater benefit with AM or PM hygiene.

DIF: Apply REF: 770

OBJ: Describe factors that influence personal hygiene practices.

TOP: Implementation MSC: Caring

5. Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Once the assessment has been done, it is important for the nurse to understand that

a.

The nursing diagnoses never change.

b.

The patients condition never changes.

c.

Critical thinking is ongoing.

d.

Hygiene needs to become a simple routine.

ANS: C

A patients condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Because hygienic care is so important for a patient to feel comfortable, refreshed, and renewed, the nurse should avoid making hygiene care a simple routine.

DIF: Understand REF: 772

OBJ: Discuss the role critical thinking plays in providing hygiene.

TOP: Assessment MSC: Caring

6. When providing hygiene for an elderly patient, it is important for the nurse to closely assess the skin. This is because as the patient ages

a.

Skin becomes more resilient.

b.

Sweat glands become more active.

c.

Skin becomes less subject to bruising.

d.

Less frequent bathing may be required.

ANS: D

Daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry. As the patient ages, the skin loses its resiliency and moisture, and sebaceous and sweat glands become less active. The epithelium thins, and elastic collagen fibers shrink, making the skin fragile and prone to bruising and breaking.

DIF: Understand REF: 771

OBJ: Conduct a comprehensive assessment of a patients total hygiene needs.

TOP: Assessment MSC: Caring

7. The nurse is bathing a patient and notices movement in the patients hair. The nurse should

a.

Ignore the movement and continue.

b.

Use gloves or a tongue blade to inspect the hair.

c.

Examine the hair without gloves to make picking lice easier.

d.

Shave the hair off of the patients head.

ANS: B

In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. Suspicions cannot be ignored. If pediculosis capitis (head lice) is suspected, the nurse must protect himself/herself against self-infestations by handwashing and by using gloves or tongue blades to inspect the patients hair. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice.

DIF: Apply REF: 776-777

OBJ: Conduct a comprehensive assessment of a patients total hygiene needs.

TOP: Implementation MSC: Caring

8. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. His drivers license states that he needs glasses to operate a motor vehicle, but no glasses were brought in with the patient. The nurse should

a.

Assume that the glasses were lost during the accident.

b.

Stand to the side of the patients eye and observe the cornea.

c.

Assume that the patient was not wearing glasses while driving.

d.

Assume that the ambulance personnel have them.

ANS: B

An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patients eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time. Examine the eyes.

DIF: Apply REF: 776

OBJ: Conduct a comprehensive assessment of a patients total hygiene needs.

TOP: Implementation MSC: Caring

9. When assessing a patients skin, the nurse needs to know that

a.

Restricted movement can increase blood circulation.

b.

Paralyzed patients have normal sensory function.

c.

Loss of subcutaneous tissue may increase the rate of wound healing.

d.

Moisture on the skin can lead to skin maceration.

ANS: D

Moisture on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require help to turn and change positions. Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue, which results in impaired or delayed wound healing.

DIF: Remember REF: 775

OBJ: Discuss conditions that place patients at risk for impaired skin integrity.

TOP: Assessment MSC: Caring

10. The nurse is caring for a patient who is immobile. The nurse is aware that the patient is at risk for Impaired skin integrity because

a.

Pressure reduces circulation to affected tissue.

b.

Patients with limited caloric intake develop thicker skin.

c.

Inadequate blood flow leads to decreased tissue ischemia.

d.

Local nerve damage leads to pain sensation.

ANS: A

Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin.

DIF: Understand REF: 775

OBJ: Discuss conditions that place patients at risk for impaired skin integrity.

TOP: Assessment MSC: Caring

11. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. The nurse realizes that patients with these conditions

a.

Have decreased pain sensation and increased risk of skin impairment.

b.

Are at decreased risk of developing infection due to urinary pH level.

c.

Also have decreased caloric intake, which results in accelerated wound healing.

d.

Have impaired venous return, allowing for greater circulation and less breakdown.

ANS: A

Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. The presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in breakdown and infection. Patients with limited caloric and protein intake develop thinner, less elastic skin, with loss of subcutaneous tissue. This results in impaired or delayed wound healing. Impaired venous return decreases circulation to the extremities. Inadequate blood flow causes ischemia and breakdown.

DIF: Understand REF: 775

OBJ: Discuss conditions that place patients at risk for impaired skin integrity.

TOP: Assessment MSC: Caring

12. The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should

a.

Not allow the patient to turn in bed because that may lead to redislocation of the leg.

b.

Restrict the patients dietary intake to reduce the number of times on the bedpan.

c.

Assess all surfaces exposed to the cast for pressure areas.

d.

Keep the patients blood pressure low to prevent overperfusion of tissue.

ANS: C

Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require assistance to turn and change positions. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.

DIF: Apply REF: 775

OBJ: Discuss conditions that place patients at risk for impaired skin integrity.

TOP: Implementation MSC: Caring

13. Of the following interventions, which would be the most important for preventing skin impairment in a mobile patient with local nerve damage?

a.

Turn the patient every 2 hours.

b.

Limit caloric and protein intake.

c.

Insert an indwelling urinary catheter.

d.

During a bath, assess for pain.

ANS: D

During a bath, assess the status of sensory nerve function by checking for pain, tactile sensation, and temperature sensation. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. The presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in impaired or delayed wound healing. However, a mobile patient can use bathroom facilities or a urinal.

DIF: Analyze REF: 775

OBJ: Discuss conditions that place patients at risk for impaired skin integrity.

TOP: Assessment MSC: Caring

14. Of the following disorders, which is caused by a virus?

a.

Corns

b.

Plantar warts

c.

Athletes foot

d.

Callus

ANS: B

Plantar warts appear on the sole of the foot and are due to the papillomavirus. Corns are caused by friction and pressure from ill-fitting or loose shoes. Athletes foot (tinea pedis) is a fungal infection. A callus is caused by local friction or pressure.

DIF: Remember REF: 776

OBJ: Discuss factors that influence the condition of the nails and feet.

TOP: Assessment MSC: Caring

15. The nurse is caring for a patient who is complaining of severe foot pain due to corns. The patient states that she has been using oval corn pads to self-treat the corns, but they seem to be getting worse. The nurse explains that

a.

Corn pads are an adequate treatment and should be continued.

b.

The patient should avoid soaking her feet before using a pumice stone.

c.

Tighter shoes would help to compress the corns and make them smaller.

d.

Depending on severity, surgery may be needed to remove the corns.

ANS: D

Surgical removal is necessary, depending on severity of pain and the size of the corn. Oval corn pads should be avoided because they increase pressure on the toes and reduce circulation. Warm water soaks soften corns before gentle rubbing with a callus file or pumice stone. Wider and softer shoes, especially shoes with a wider toe box, are helpful.

DIF: Understand REF: 776

OBJ: Discuss factors that influence the condition of the nails and feet.

TOP: Planning MSC: Teaching/Learning

16. The patient is diagnosed with athletes foot (tinea pedis). The patient says that she is relieved because it is only athletes foot, and it can be treated easily. The nurse explains that athletes foot is

a.

Generally isolated to the feet and never recurs.

b.

Contagious and frequently recurs.

c.

Caused by the papillomavirus.

d.

Treated with salicylic acid or electrodesiccation.

ANS: B

Athletes foot spreads to other body parts, especially the hands. It is contagious and frequently recurs. It is caused by a fungus, not the papillomavirus, and is treated with applications of griseofulvin, miconazole, or tolnaftate. It is not treated with salicylic acid or electrodesiccation. Those are treatments for plantar warts.

DIF: Understand REF: 776

OBJ: Discuss factors that influence the condition of the nails and feet.

TOP: Planning MSC: Teaching/Learning

17. When assessing a patients feet, the nurse notices that the toenails are thick and separated from the nail bed. The nurse is aware that this condition is caused by

a.

Fungi.

b.

Nail polish.

c.

Friction.

d.

Nail polish remover.

ANS: A

Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Friction and pressure from ill-fitting or loose shoes causes keratosis (corns). It is seen mainly on or between toes, over bony prominences.

DIF: Remember REF: 775-776

OBJ: Explain the importance of foot care for the diabetic patient.

TOP: Assessment MSC: Nursing Process

18. The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because

a.

Plantar warts can develop from foot fungi.

b.

Poor foot care leads to neuropathy.

c.

A strong dorsalis pedis pulse indicates poor blood flow.

d.

Foot ulcers are the most common precursor to amputation.

ANS: D

Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Plantar warts are due to the papillomavirus, not to a fungus. Palpation of the dorsalis pedis and posterior tibial pulses indicates that adequate blood flow is reaching peripheral tissues. Neuropathy is a degeneration of the peripheral nerves usually due to poor control of blood glucose levels; it is not a direct result of poor foot care.

DIF: Understand REF: 775-776

OBJ: Explain the importance of foot care for the diabetic patient.

TOP: Assessment MSC: Nursing Process

19. The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. The term for bad breath is

a.

Alopecia.

b.

Halitosis.

c.

Dental caries.

d.

Neuropathy.

ANS: B

Halitosis is the term for bad breath. Alopecia indicates hair loss. Dental caries are cavities in the teeth. Neuropathy is a degeneration of peripheral nerves leading to loss of sensation in the extremities.

DIF: Remember REF: 775

OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Assessment MSC: Nursing Process

20. The nurse is caring for an unresponsive patient who has a nasogastric tube in place for continuous tube feedings. The nurse assesses the patients oral hygiene because good oral hygiene

a.

Helps prevent gingivitis.

b.

May cause glossitis.

c.

May lead to halitosis.

d.

Causes tongue coating.

ANS: A

Early identification of poor oral hygiene practices and common oral problems reduces the risk for gum disease and dental caries. Patients frequently develop common oral problems as a result of inadequate oral care or as a consequence of disease (e.g., oral malignancy) or as a side effect of treatments such as radiation and chemotherapy. These problems include receding gum tissue, inflamed gums (gingivitis), a coated tongue, glossitis (inflamed tongue), discolored teeth (particularly along gum margins), dental caries, missing teeth, and halitosis (foul-smelling breath).

DIF: Understand REF: 775-776

OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Assessment MSC: Nursing Process

21. The patient is being treated for cancer with weekly radiation and chemotherapy treatments. The nurse is aware that the patients oral mucosa needs to be assessed because chemotherapy and radiation can

a.

Increase saliva production.

b.

Decrease the risk of oral inflammation.

c.

Decrease drying of oral mucosa.

d.

Lead to oral problems.

ANS: D

Patients frequently develop common oral problems as a result of inadequate oral care or as a consequence of disease (e.g., oral malignancy) or as a side effect of treatments such

as radiation and chemotherapy.

DIF: Understand REF: 775

OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Assessment MSC: Nursing Process

22. In providing oral care to an unconscious patient, it is important for the nurse to

a.

Moisten the mouth using lemon-glycerin sponges.

b.

Hold the patients mouth open with his or her fingers.

c.

Rinse the mouth and immediately suction the oral cavity.

d.

Use foam swabs to help remove plaque.

ANS: C

When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care. One nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patients mouth open. A human bite contains multiple pathogenic microorganisms.

DIF: Apply REF: 786

OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Implementation MSC: Caring

23. The nurse is teaching the patient about flossing and oral hygiene. The nurse teaches the patient that

a.

Flossing needs to be done at least three times a day.

b.

To prevent bleeding, the patient should use waxed floss.

c.

Flossing removes plaque and tartar from the teeth.

d.

Applying toothpaste to the teeth before flossing is harmful.

ANS: C

Dental flossing removes plaque and tartar between teeth. To prevent bleeding, the patient should use unwaxed floss. Flossing once a day is sufficient. If toothpaste is applied to the teeth before flossing, fluoride will come in direct contact with tooth surfaces, aiding in cavity prevention.

DIF: Apply REF: 786

OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes.

TOP: Implementation MSC: Caring

24. The nurse is caring for a patient who has head lice (pediculosis capitis). The nurse knows that in treating this condition, one must understand that

a.

Products containing lindane are most effective.

b.

Head lice may spread to furniture and other people.

c.

Treatment must be repeated in 7 to 10 days.

d.

Manual removal is not a realistic option as treatment.

ANS: B

Head lice are difficult to remove and spread to furniture and other people if not treated. Caution against use of products containing lindane because the ingredient is toxic and is known to cause adverse reactions. Treatments need to be repeated 12 to 24 hours after the initial treatment. Manual removal is the best option when treatment has failed.

DIF: Understand REF: 777

OBJ: List common hair and scalp problems and their related interventions.

TOP: Assessment MSC: Caring

25. Scaling of the scalp accompanied by itching is known as

a.

Dandruff.

b.

Pediculosis.

c.

Alopecia.

d.

Ticks.

ANS: A

Dandruff is scaling of the scalp that is accompanied by itching. Pediculosis (lice) consists of tiny, grayish-white parasite insects that infest mammals. Alopecia is hair loss or balding. Ticks are small, gray-brown parasites that burrow into the skin and suck blood.

DIF: Remember REF: 777

OBJ: List common hair and scalp problems and their related interventions.

TOP: Assessment MSC: Caring

26. In examining a patient for pediculosis capitis (head lice), the nurse would expect to find

a.

Grayish-white parasites with red legs.

b.

Pustules or bites behind ears and at the hairline.

c.

Balding patches in periphery of the hairline.

d.

Brittle and broken hair.

ANS: B

With head lice, the parasite is on the scalp attached to hair stands. Bites or pustules may be observed behind the ears and at the hairline. Grayish-white parasites with red legs are pediculosis pubis (crab lice), not head lice, and are found in pubic hair. Alopecia (hair loss) is found in all races, with brittle and broken hair and balding patchiness in the periphery of the hairline.

DIF: Remember REF: 777

OBJ: List common hair and scalp problems and their related interventions.

TOP: Assessment MSC: Caring

27. The nurse is caring for a patient who has multiple ticks on her legs and body. To rid the patient of ticks, the nurse should

a.

Burn the ticks in an ashtray once removed.

b.

Use blunt tweezers and pull upward with steady pressure.

c.

Allow the ticks to drop off by themselves.

d.

Use products containing lindane to kill the ticks.

ANS: B

Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick. Because ticks transmit several diseases to people, they must be removed. Allowing them to drop off by themselves is not an option. Lindane is an ingredient that was used in treatment for pediculosis capitis (head lice); it should no longer be used because the ingredient is toxic and is known to cause adverse reactions.

DIF: Apply REF: 777

OBJ: List common hair and scalp problems and their related interventions.

TOP: Implementation MSC: Caring

28. The patient is diagnosed with pediculosis capitis (head lice) and was treated upon admission and was re-treated 24 hours later, yet the patient is still infested. The nurse should next

a.

Re-treat the patient with a medicated shampoo for eliminating lice.

b.

Use a product containing lindane to get rid of the lice.

c.

Manually remove the lice using a fine-toothed comb.

d.

Have the patient bathe or shower thoroughly.

ANS: C

Manual removal is the best option when treatment has failed. Re-treating with a medicated shampoo may lead to adverse reactions and should not be done without consulting the care provider. Products containing lindane should not be used because the ingredient is toxic and is known to cause adverse reactions. Although bathing or showering is a good idea, this is usually considered a treatment for pediculosis corporis (body lice), not pediculosis capitis (head lice).

DIF: Apply REF: 777

OBJ: List common hair and scalp problems and their related interventions.

TOP: Implementation MSC: Caring

29. The nurse is caring for an elderly patient with Alzheimers disease who is ambulatory but requires total assistance with his activities of daily living (ADLs). The nurse notices that his skin is dry and wrinkled. The nurse should

a.

Make sure that the patient is receiving daily baths.

b.

Reduce the number of baths per week if possible.

c.

Be aware that sweat glands become more active with aging.

d.

Be sure that the patient is using soap with his bath.

ANS: B

Decreasing the number of baths per week may help prevent further drying of the skin. As people age, the skin loses its resiliency and moisture, and sebaceous and sweat glands become less active. Daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry.

DIF: Apply REF: 774-775

OBJ: Describe how hygiene care for the older adult differs from that for the younger patient.

TOP: Implementation MSC: Caring

30. A self-sufficient bedridden patient unable to reach all body parts needs which type of bath?

a.

Complete bed bath

b.

Bag bath

c.

Sponge bath

d.

Partial bed bath

ANS: D

A partial bath consists of washing body parts that the patient cannot reach, including the back, and providing a back rub. Dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. Complete bed baths are administered to totally dependent patients in bed. The bag bath contains several soft, nonwoven cotton cloths that are pre-moistened in a solution of no-rinse surfactant cleanser and emollient. It can be used for any patient. The sponge bath involves bathing from a bath basin or a sink with the patient sitting in a chair.

DIF: Remember REF: 783

OBJ: Discuss the different approaches using in maintaining a patients comfort during hygiene care.

TOP: Assessment MSC: Caring

31. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. She does this for which of the following reasons?

a.

Washbasins can harbor gram-negative organisms.

b.

Bag baths use soaps that enhance cleansing.

c.

Bag baths do not contain emollients.

d.

Bag baths increase skin flaking and scaling.

ANS: A

When washbasins are not cleaned and dried completely after use, the risk of contamination by gram-negative organisms is introduced. Successive uses of the washbasin cause the patients skin to harbor more gram-negative organisms. Bag baths do not contain soap. Instead, they contain a no-rinse surfactant, a humectant to trap moisture, and an emollient that significantly reduces overall skin dryness, especially skin flaking and scaling.

DIF: Understand REF: 784

OBJ: Discuss the different approaches using in maintaining a patients comfort during hygiene care.

TOP: Assessment MSC: Caring

32. The female nurse is caring for a male patient who is uncircumcised but not ambulatory, although he has full function of arms and hands. The nurse is providing the patient with a partial bed bath. Perineal care for this patient

a.

Is not necessary because he is not circumcised.

b.

Should be postponed because it may cause him embarrassment.

c.

Should be done by the patient.

d.

Should be done by the nurse.

ANS: C

Patients most in need of perineal care are those at greatest risk for acquiring an infection such as uncircumcised males. If a patient is able to perform perineal self-care, encourage this independence. Embarrassment should not cause the nurse to overlook the patients hygiene needs. The nurse should provide this care only if the patient is unable to do so.

DIF: Apply REF: 784-785

OBJ: Discuss the different approaches using in maintaining a patients comfort during hygiene care.

TOP: Implementation MSC: Caring

33. After the patients bath, the nurse should

a.

Not offer a backrub because it is not therapeutic.

b.

Routinely give backrubs of 2 minutes or less.

c.

Assume that all patients need backrubs after their bath.

d.

Not offer a backrub for 48 hours after coronary artery bypass surgery.

ANS: D

Consult the medical record for any contraindications to a massage (e.g., fractured ribs, burns, heart surgery). A backrub of 3 minutes duration actually enhances patient comfort and relaxation and thus is very therapeutic. It is important to ask whether a patient would like a backrub because some individuals dislike physical contact.

DIF: Apply REF: 785

OBJ: Discuss the different approaches using in maintaining a patients comfort during hygiene care.

TOP: Implementation MSC: Caring

34. When providing the patient with a complete bed bath using soap and water (not a bag bath), it is important to

a.

Use alkaline soaps to help prevent infection.

b.

Towel dry completely to prevent maceration.

c.

Use soap liberally when cleansing the eyes.

d.

Cleanse the eye from outer canthus to inner canthus.

ANS: B

Moisture and sediment that collect in skinfolds predispose skin to maceration. Towel dry to prevent maceration. Soap irritates the eyes. Use of separate sections of the mitt reduces infection transmission. Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct. Alkaline soap residue is irritating to skin and can decrease the normal protectiveness of acid pH.

DIF: Apply REF: 799-800

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Caring

35. The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). In doing so, the nurse should

a.

Use one towel for the entire bath.

b.

Dry the skin with a towel.

c.

Allow the skin to air dry.

d.

Not use a bath blanket or towel.

ANS: C

The nurse should allow the skin to air dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. The cleansing pack contains eight to ten pre-moistened towels for cleansing. Use a single towel for each general body part cleansed.

DIF: Apply REF: 803

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

36. In providing perineal care to a female patient, the nurse should wash

a.

Upward from rectum to pubic area.

b.

From back to front.

c.

From pubic area to rectum.

d.

In a circular motion.

ANS: C

Cleansing from pubic area to rectum (front to back) reduces the transfer of microorganisms to the urinary meatus and decreases the risk of urinary tract infection. Cleansing from rectum to pubic area or back to front increases the risk of urinary tract infection. Circular motions are used in male perineal care.

DIF: Apply REF: 801

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

37. The nurse is providing perineal care to an uncircumcised male patient. When providing such care, the nurse should

a.

Leave the foreskin alone because there is little chance of infection.

b.

Retract the foreskin for cleansing and allow it to return on its own.

c.

Retract the foreskin and keep retracted.

d.

Retract the foreskin and return it to its natural position when done.

ANS: D

Return the foreskin to its natural position. Keeping the foreskin retracted leads to tightening of the foreskin around the shaft of the penis, causing local edema and discomfort. The foreskin may not return to its natural position on its own. Patients at greatest risk for infection are uncircumcised males.

DIF: Apply REF: 802

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

38. Patients with diabetes mellitus need special foot care to prevent the development of ulcers. Knowing this, the nurse

a.

Trims the patients toenails daily.

b.

Has the patient soak his or her feet twice a day.

c.

Requests a consult with a nail care specialist.

d.

Assesses the brachial artery.

ANS: C

Patients with peripheral vascular disease or diabetes mellitus often require nail care from a specialist to reduce the risk of infection. Some agencies allow cutting of nails with a providers order; however, most do not. Patients with diabetes do not soak hands and feet. Soaking increases the risk of infection because of maceration of the skin. When assessing the patients feet, the nurse palpates the dorsalis pedis of the foot, not the brachial artery.

DIF: Apply REF: 805

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

39. The unconscious patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, the nurse may

a.

Insert an oral airway upside down.

b.

Hold the patients mouth open with her fingers.

c.

Position the patient on his back.

d.

Use undiluted hydrogen peroxide as a cleaner.

ANS: A

If the patient is unconscious or uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, then turn the airway sideways and over the tongue to keep the teeth apart. Insert when the patient is relaxed. Do not use force. Never place fingers into the mouth of an unconscious or debilitated patient. The normal response of the patient is to bite down. Position the patient on his side or turn his head to allow for drainage. Placing the patient on his back could lead to aspiration. Hydrogen peroxide and sodium bicarbonate effectively remove debris but, if not diluted carefully, may cause superficial burns.

DIF: Apply REF: 812

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

40. When providing basic eye care, the nurse

a.

Cleanses the eye with soap and water.

b.

Applies pressure directly to the eyeball.

c.

Cleanses from inner canthus to outer canthus.

d.

Provides less frequent care to unconscious patients.

ANS: C

When cleansing the patients eyes, obtain a clean washcloth and cleanse from inner canthus to outer canthus. Use a different section of the washcloth for each eye. Cleansing simply involves washing with a clean washcloth moistened in water. Soap causes burning and irritation. Never apply direct pressure over the eyeball because this causes serious injury. Unconscious patients often require more frequent eye care.

DIF: Apply REF: 789

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

41. The nurse is teaching a patient about contact lens care. The patient has plastic lenses, so the nurse instructs the patient to

a.

Use tap water to clean lenses.

b.

Keep the lenses is a cool dry place when not being used.

c.

Reuse storage solution for up to a week.

d.

Wash and rinse lens storage case daily.

ANS: D

Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically with soap or liquid detergent, rinse thoroughly with warm water, and air dry. Do not use tap water to clean lenses because tap water is not sterile and can introduce microorganisms. Lenses should be kept moist or wet when not worn. Use fresh solution daily when storing and disinfecting lenses.

DIF: Apply REF: 790

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

42. The patient complains to the nurse about a perceived decrease in hearing. When the nurse examines the patients ear, she notices a large amount of cerumen (ear wax) buildup at the entrance to the ear canal. The nurse should

a.

Apply gentle, downward retraction of the ear canal.

b.

Tell the patient to use a bobby pin to extract earwax.

c.

Teach the patient how to use cotton-tipped applicators.

d.

Instill hot water into the ear canal to melt the wax.

ANS: A

When cerumen is visible, gentle, downward retraction at the entrance to the ear canal causes the wax to loosen and slip out. Instruct the patient never to use sharp objects such as bobby pins or paper clips to remove earwax. Use of such objects traumatizes the ear canal and ruptures the tympanic membrane. Avoid the use of cotton-tipped applicators as well because they cause earwax to become impacted within the canal. Instilling cold or hot water causes nausea or vomiting.

DIF: Apply REF: 791

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

43. The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, the nurse instructs the patient to

a.

Wear the hearing aid 24 hours per day except when sleeping.

b.

Change the battery every day or as needed.

c.

Avoid the use of hairspray, but aerosol perfumes are allowed.

d.

Adjust the volume for a talking distance of 1 yard.

ANS: D

Adjust volume to a comfortable level for talking at a distance of 1 yard. Initially, wear a hearing aid for 15 to 20 minutes; then gradually increase wear time to 10 to 12 hours per day. Batteries last 1 week with daily wear of 10 to 12 hours. Avoid the use of hairspray and perfume while wearing hearing aids. Residue from the spray can cause the aid to become oily and greasy.

DIF: Apply REF: 792

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

44. The patient is complaining of an inability to clear his nasal passages. The nurse instructs the patient to

a.

Blow his nose forcefully to clear the passage.

b.

Insert a cotton-tipped applicator as far as possible.

c.

Apply gentle suction using a pediatric bulb suction device.

d.

Use a dry washcloth to absorb secretions.

ANS: C

Excessive nasal secretions can be removed using gentle suctioning. However, patients usually remove secretions from the nose by gentle blowing into a soft tissue. Caution the patient against harsh blowing that creates pressure capable of injuring the eardrum, the nasal mucosa, and even sensitive eye structures. If the patient is unable to remove nasal secretions, assist by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip.

DIF: Apply REF: 792

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Implementation

MSC: Caring

45. Of the following hearing aids, which interferes the most with wearing eyeglasses and using a phone?

a.

In-the-canal hearing aid

b.

In- the-ear hearing aid

c.

Behind-the-ear hearing aid

d.

They are all equally useful.

ANS: C

The behind-the-ear aid hooks around and behind the ear and is connected by a short, clear, hollow plastic tube to an ear mold inserted into the external auditory canal. It is useful for patients with rapidly progressive hearing loss or manual dexterity difficulties, but it is more visible and interferes with wearing eyeglasses and using a phone. An in-the-canal aid is the newest, smallest, and least visible and fits entirely in the ear canal. It does not interfere with wearing eyeglasses or using the telephone, but it does not accommodate progressive hearing loss and requires manual dexterity to operate. An in-the-ear aid does not interfere with wearing of eyeglasses or phone usage, but it is more noticeable than the in-the-canal aid and is not useful for persons with skin problems in the ear canal.

DIF: Evaluate REF: 791

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Caring

MULTIPLE RESPONSE

1. The nurse is admitting an elderly patient for failure to thrive and weight loss. A nasogastric tube is inserted for supplemental tube feedings. The nurse should become concerned when (Select all that apply.)

a.

Bleeding is noted where the tube comes in contact with the nares.

b.

Nasal mucosa is pink.

c.

No discharge from the nose is noted.

d.

Clear, watery discharge is noted.

ANS: A, D

If patients have any form of tubing exiting the nose (e.g., nasogastric), observe for tissue damage, localized tenderness, inflammation, drainage, and bleeding where the tubing comes in contact with the nares. Allergies cause a clear, watery discharge. The nasal mucosa is normally pink and clear and has little or no discharge.

DIF: Understand REF: 777

OBJ: Describe how hygiene care for the older adult differs from that for the younger patient.

TOP: Assessment MSC: Caring

2. The use of critical thinking attitudes is necessary to design a plan of care to meet the patients hygiene needs. Which of the following are considered critical thinking attitudes? (Select all that apply.)

a.

Curiosity

b.

Communication principles

c.

Prior experience

d.

Humility

e.

Knowledge of cultural variations

ANS: A, D

Use of critical thinking attitudes, such as curiosity and humility, is necessary to design a plan of care to meet the patients hygiene needs. Communication principles and knowledge of cultural variations in hygiene are considered knowledge elements, and prior experience is part of the experience elements of the critical thinking model for hygiene assessment.

DIF: Remember REF: 772

OBJ: Discuss the role critical thinking plays in providing hygiene.

TOP: Implementation MSC: Caring

3. Of the following developmental changes, which are most commonly associated with the elderly? (Select all that apply.)

a.

Increased eccrine and apocrine gland function

b.

Fungal nail infections

c.

Less resilient skin and bruising

d.

Increased skin lubrication

e.

Dry, itchy skin

ANS: B, C, E

Common problems of the feet affecting older adults include corns, calluses, bunions, hammer toe, and fungal infections. Long or roughened nails lead to traumatic nail avulsions in which the nail plate is torn from the nail bed. Older adults often have dry feet because of a decrease in sebaceous gland secretion and dehydration of epidermal cells. With aging, the rate of epidermal cell replacement slows, and the skin thins and loses resiliency. Moisture leaves the skin, increasing the risk for bruising and other types of injury. As production of lubricating substances by skin glands decreases, the skin becomes dry and itchy.

DIF: Remember REF: 771-772

OBJ: Describe how hygiene care for the older adult differs from that for the younger patient.

TOP: Assessment MSC: Caring

4. Of the following patients, which are in need of perineal care? (Select all that apply.)

a.

A patient with urinary and fecal incontinence

b.

A circumcised male who is ambulatory

c.

A patient with rectal and perineal surgical dressings

d.

A patient with an indwelling catheter

e.

A morbidly obese patient

ANS: A, C, D, E

Patients at greatest risk for skin breakdown in the perineal area are those with urinary or fecal incontinence, rectal and perineal surgical dressings, or indwelling urinary catheters, along with the morbidly obese. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide self-perineal care.

DIF: Evaluate REF: 784-785

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Caring

5. The patient has been forcefully blowing his nose and now has a nosebleed. The nurse is concerned about the patients condition and assesses the patient for which possible negative issues? (Select all that apply.)

a.

Clearance of nasal passages

b.

Injury to the tympanic membrane (eardrum)

c.

Damage to nasal mucosa

d.

Eye injury

e.

Decreased nasal passage pressure

ANS: B, C, D

Caution the patient against harsh blowing that creates pressure capable of injuring the eardrum, nasal mucosa, and even sensitive eye structures. Clearing the nasal passages is the goal of nose blowing and is not a negative issue. Harsh blowing increases (not decreases) nasal passage pressure.

DIF: Evaluate REF: 792

OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Caring

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