Deck 27: Hygiene and Personal Care

Question 1

The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next?

A) Moisten the finger with lens solution and gently touch it to pick it up.
B) Moisten the contact lens with tap water and pick it up.
C) Pick it up and insert the contact lens.
D) Discard the contact lens.

Answer 1

Moisten the finger with lens solution and gently touch it to pick it up.

Question 2

The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of hygiene self-care deficit. Which goal is most appropriate on day one?

A) Patient will ambulate independently twice a day.
B) Patient will perform all of own ADLs.
C) Patient will consume 75% of all meals.
D) Patient will begin to perform 50% of own ADLs.

Answer 2

Patient will begin to perform 50% of own ADLs.

Question 3

The nurse knows that routine hygienic care does not include:

A) massage with lotion.
B) oral care with a toothbrush.
C) shaving with a disposable razor.
D) ear hygiene with cotton-tipped applicators.

Answer 3

ear hygiene with cotton-tipped applicators.

Question 4

The nurse knows that which areas are at increased risk of excoriation? (Select all that apply.)

A) Exposed areas such as the face
B) Areas exposed to stool
C) Skin on skin areas
D) Area under pendulous breasts

Question 5

Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient?

A) Nurse
B) Physical therapist
C) Occupational therapist
D) Podiatrist

Question 6

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?

A) High Fowler's
B) Prone
C) Side lying
D) Low Fowler's

Question 7

The nurse knows that which of the following statements is true regarding the importance of hygiene?

A) The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath.
B) UAPs perform hygiene because there is no benefit of nurses doing it.
C) The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene.
D) The main purpose of bathing is to decrease odor.

Question 8

The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect?

A) The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient.
B) The nurse rolls dirty linens to the side then places the linens on the floor while finishing.
C) The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens.
D) The nurse wears gloves to remove dirty linens.

Question 9

The nurse is performing perineal care for the uncircumcised patient. Which of the following is true?

A) The foreskin should not be moved.
B) The foreskin should be retracted, pulling it away from the body.
C) The foreskin should be left retracted and allowed to return to position naturally after care.
D) The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying.

Question 10

The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action?

A) Refuse to shave the patient because he is on an anticoagulant.
B) Shave as usual with a safety razor.
C) Offer to wax rather than shave the patient.
D) Use an electric razor.

Question 11

The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:

A) ineffective health maintenance.
B) readiness for enhanced self-care.
C) hygiene self-care deficit.
D) disturbed body image.

Question 12

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?

A) Patient with asthma
B) Patient with attention deficit hyperactivity disorder
C) Patient with a stroke
D) Patient with diabetes

Question 13

What statement is true regarding oral care of patients on anticoagulants?

A) Use an electric toothbrush daily.
B) Avoid oral care.
C) Use mouthwash only.
D) Use a soft-bristled toothbrush.

Question 14

Regarding denture care, what action by the nurse is inappropriate?

A) Carrying the dentures to the sink wrapped in a paper towel.
B) Placing a towel in the sink and brushing the dentures over the towel.
C) Brushing the dentures as the nurse would the teeth of a conscious patient.
D) Applying adhesive, then inserting upper and then lower dentures.

Question 15

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first?

A) Hands
B) Eyes
C) Face
D) Arms

Question 16

Which statement by the patient indicates a teaching need?

A) "I use bobby pins to remove excessive ear wax."
B) "I use soap and a warm cloth to clean the outside of my ear."
C) "My doctor sometimes gives me oil drops for my ears."
D) "I never use Q-Tips."

Question 17

Which tool is used to determine risk for impaired skin integrity?

A) Braden scale
B) Glasgow scale
C) Vanderbilt scale
D) MMSE scale

Question 18

Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable nursing diagnosis for a patient with excessively dry skin?

A) Imbalanced Nutrition: Less than body requirements
B) Deficient fluid volume
C) Risk for infection
D) Acute pain

Question 19

The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate?

A) To promote circulation
B) To maintain asepsis
C) To maintain comfort
D) To maintain tradition

Question 20

The nurse has assisted the patient to wash his hands, face, axillae, and perineal area. What type of bath should the nurse chart?

A) Sink bath
B) Complete bed bath
C) Partial bed bath
D) Shower

Question 21

The nurse should avoid soaking the feet of which patient population? (Select all that apply.)

A) Patients with peripheral vascular disease
B) Patients with a stroke
C) Patients with diabetes
D) Patients with arthritis

Question 22

The nurse notes that a trauma patient has multiple tangles in the hair. Which of the following actions taken by the nurse is appropriate? (Select all that apply.)

A) Work the tangles to the ends of the hair, then trim with scissors.
B) Apply warm water and conditioner.
C) Apply detangler as available.
D) Use a comb or fingers to work through tangles.

Question 23

The nurse is demonstrating cultural sensitivity in performing perineal care when he/she does the following: (Select all that apply.)

A) The male nurse delegates perineal care of a female patient to the female UAP.
B) The male nurse asks a female patient if she would prefer a female to perform care.
C) The nurse approaches the care in a sensitive, professional manner.
D) The nurse assesses cultural preferences of the patient prior to care.

Question 24

The nurse is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.)

A) Bathing
B) Oral care
C) Perineal care
D) Foot care
E) Patient communication
F) None of the above

Question 25

The nurse is bathing a patient and notes reddened skin above the coccyx. Which action by the nurse is appropriate? (Select all that apply.)

A) Apply a barrier cream and massage the area.
B) Document and describe the area and report to the physician.
C) Wash and dry the area and position patient without pressure on coccyx.
D) Report the area to the charge nurse.

Question 26

Regarding perineal care, which nursing action is appropriate? (Select all that apply.)

A) The nurse applies gloves prior to performing perineal care
B) The nurse ignores the erection of a male patient during perineal care
C) The nurse documents the perineal care.
D) The nurse only completes perineal care with daily bathing