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Chapter 40. Hygiene - Test Bank
Fundamentals of Nursing (165)
University of California Los Angeles
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Chapter 40. Hygiene
MULTIPLE CHOICE
- The client has a red, raised skin rash. During the bath, the priority action of the nurse is to: a. Assess for further inflammatory reactions b. Discuss the body image problems created by the presence of the rash c. Wash the skin thoroughly with hot water and soap d. Moisturize the skin to prevent drying
ANS: A The first action the nurse should take is to assess for further inflammatory reactions to determine if it is localized or systemic. Discussing bod y 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.
PTS: 1 DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. Poor nutrition b. Immobility c. Reduced hydration d. Skin secretions
ANS: B 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 client’s greatest risk factor is having impaired mobility.
PTS: 1 DIF: A REF: 855 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse delegates the hygienic care of a male client to the nursing assistant. In reviewing the client assignment, the nurse instructs the assistant to make sure to use an electric razor to shave the client with: a. Thrombocytopenia b. Congestive heart failure c. Osteoarthritis d. Pneumonia
ANS: A 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
PTS: 1 DIF: C REF: 893 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would be evaluated as appropriate? a. Placing dentures in a tissue while not worn b. Cutting the clients nails with scissors c. Using soap to cleanse the eye orbits d. Washing the client’s legs with long strokes from the ankle to the knee
ANS: D To promote venous return, the nursing assistant should use long strokes, washing the client’s 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 client’s 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 client’s eyes should be washed with plain water as soap irritates eyes.
PTS: 1 DIF: C REF: 873 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- A 61-year-old client with diabetes mellitus has physician’s orders for meticulous foot care. Which of the following is the best rationale for the order? a. The aging process causes increased skin breakdown. b. There is increased neuropathy with this pathology that places the client at risk. c. The client probably has a history of poor hygienic care. d. The lower extremities are difficult to see and therefore hard to maintain with good hygiene.
ANS: B 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., 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 client’s 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 client’s greatest risk for developing a foot ulcer is diabetic neuropathy.
PTS: 1 DIF: C REF: 853 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. Long, firm strokes down the back b. Light strokes while moving up the back in a circular motion c. Kneading movements toward the sacrum d. Circular motion upward from buttocks to shoulders
ANS: A
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 person’s daily routines and the condition of the hair.
PTS: 1 DIF: C REF: 890 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- A client has recently experienced difficulty hearing out of both ears. Which of the following is the best nursing response to the client? a. Let’s irrigate your ears with cool water. b. Can you turn your head toward me when I am talking to you? c. Your hearing aid should not need a new battery for at least 3 months. d. Try to avoid putting a Q-Tip (cotton-tipped applicator) into your ears.
ANS: D Use of cotton-tipped applicators should be avoided because they can ca use 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.
PTS: 1 DIF: C REF: 895 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- An adolescent client with acne should be taught by the nurse to: a. Apply moisturizing lotions or creams b. Wash the face and hair daily with very warm water and soap c. Use a depilatory to remove excess hair d. Add moisture to the air with the use of a humidifier
ANS: B 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.
PTS: 1 DIF: A REF: 885 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: a. Powerlessness b. Self-care deficit c. Tissue integrity impairment d. Knowledge deficit of hygiene practices
ANS: B 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.
PTS: 1 DIF: A REF: 862 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- A different approach to traditional hygienic care is the bag bath. The best rationale for using this approach is because it is: a. Less expensive than the traditional method b. Takes less time to complete c. Leaves the skin softer d. Reduces the risk of infection
ANS: A 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 client’s 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.
PTS: 1 DIF: A REF: 868 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse is preparing to assist the adult female client with perineal care. The position of choice for this client is: a. Dorsal recumbent b. Side-lying c. Supine d. Prone
ANS: A 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.
PTS: 1 DIF: A REF: 868 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- A client who is suspected of having vascular insufficiency to the lower extremities is assessed by the nurse to have a(n): a. Increased hair growth on the legs and feet b. Dull appearance of the skin c. Erythema upon elevation of the feet d. Diminished pedal pulses
ANS: D 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.
TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process? a. I work with my ancillary staff to be able to determine what is abnormal. b. The skin is easy to observe for abnormalities when you are giving the bath. c. I use the time to really look at m y clients and determine what’s normal and what’s not. d. Bath time is an excellent time to get to know your clients and form that nurse -client relationship.
ANS: C 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., 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.
PTS: 1 DIF: C REF: 869 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- Which of the following statements best reflects the nurse’s knowledge of the effect of skin integrity on a client’s general state of health? a. When I keep the skin healthy, the client is healthy. b. If the skin isn’t in good shape, illness isn’t far away. c. I believe cleanliness is a top priority for comfort and health. d. If a client is able to do their own hygiene care, they feel in control.
ANS: B 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 client’s state of health.
PTS: 1 DIF: C REF: 854 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. Skin appears generally jaundiced. b. Dryness noted on heels and elbows bilaterally. c. Skin tears present on upper left and right arms. d. Skin on the hands and feet is slightly cool to the touch.
ANS: A 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.
PTS: 1 DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- Which of the following statements made by the nurse reflects the best understanding of the effect of dry skin on a client’s general health and well-being? a. When her skin is cracked, she is so much more uncomfortable. b. Keeping the skin moist is so much easier than making the skin moist. c. She is such a proud lady; dry, cracked skin makes her feel unattractive. d. If I can keep her skin moisturized, it will be less likely to crack and bleed.
ANS: D 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.
PTS: 1 DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. At times you have to really work at getting her to agree to having a bath. b. I learned that an evening bath is what she is used to, so Ill bathe her before bed. c. She seemed to enjoy her morning bath; Ill bathe her again this evening after dinner. d. She really enjoys that mildly scented vanilla soap her daughter brought her yesterday.
ANS: C 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.
PTS: 1 DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Comprehension MSC: NCLEX test plan designation: Physiological Integrity/ Basic Care & Comfort/Personal
- The nurse should expect that which of the following clients is most likely to have difficulty performing personal hygiene tasks? a. The 54-year -old with osteoarthritis in his upper extremity joints b. The 26-year -old new mother experiencing postpartum depression c. The 15-year -old client who fractured his left clavicle while skateboarding d. The 36-year -old client who just learned that her lung cancer is inoperable
ANS: A Any condition that interferes with movement of the hand (e., superficial or deep pain or joint inflammation) impairs a client’s 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.
PTS: 1 DIF: C REF: 860 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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: a. Comfort level b. Nutritional status c. Physical recovery d. Emotional well-being
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.
PTS: 1 DIF: C REF: 893 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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: a. A cultural preference b. A personal idiosyncrasy c. His psychiatric diagnosis d. A need for personal control
ANS: A Among Hindus and Muslims, the left hand is used for cleaning, whereas the right hand is used for eating and praying.
PTS: 1 DIF: C REF: 860 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. Will you need my help to take a bath? b. Does taking a bath or shower cause you any pain? c. Can you bathe and dress yourself without needing help? d. Do you find yourself getting tired before you’re finished bathing?
ANS: D 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.
PTS: 1 DIF: C REF: 863 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. Bad skin is a part of being a teenager; but don’t make it worse with poor hygiene habits. b. Bad skin is often affected by what you eat, so eat a healthy, well-balanced diet of low-fat foods. c. If the acne gets really bad, then see your health care provider for a prescript ion for a topical antibiotic. d. 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: D 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.
PTS: 1 DIF: C REF: 855 OBJ: Analysis
TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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: a. Determine when the angiocatheter was inserted b. Ask the client if the area appears reddened c. Take an axillary temperature on the same side as the IV site d. Use the back of the hand to assess skin temperature at the site
ANS: D 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.
PTS: 1 DIF: C REF: 856 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse is discussing skin hygiene with a group of adolescent athletes. The nurse plans to discuss the prevention and management of athlete’s foot primarily because: a. It is a common skin disorder among this particular population b. It is both easily prevented and managed if you understand the problem c. The condition can spread to other parts of the body if not managed well d. The condition is often a source of social embarrassment for those who have it
ANS: C 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.
PTS: 1 DIF: C REF: 857 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. My mother tells me that toe rings will cause me to develop calluses. b. Its expensive buying new shoes just because your feet keep growing. c. I throw my sneakers into the washing machine regularly to keep the inside surfaces clean. d. I cut the discolored nails on both of my great toes really short to make them a little less noticeable.
ANS: D Ingrown nails often result from improper nail trimming. The remaining options are correct and do not require follow-up
PTS: 1 DIF: C REF: 857 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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: a. The lice may carry various other serious diseases b. The parasites are extremely difficult to remove and kill c. The presence of lice typically reflects poor hygiene practices
d. With very hot water and vigorous rubbing to remove dead skin cells
ANS: B 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 don’t 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.
PTS: 1 DIF: B REF: 853 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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 client’s sensation to light touch, pinprick, and temperature to determine if she has: a. Glaucoma b. Psoriasis c. Neuropathy d. Dermatitis
ANS: C 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 client’s 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.
PTS: 1 DIF: A REF: 884 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- On examining a client’s fingernails, the nurse notes that they are excessively dry. The nurse knows that this can be caused by which of the following? a. Fungal nail infections b. Dry climates c. Washing dishes by hand d. Polishing nails, and using polish remover
ANS: D Ask women whether they frequently polish their nails and use polish remover, because chemicals in these products cause excessive nail dry ness. 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
PTS: 1 DIF: A REF: 867 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse knows that she needs to provide additional teaching to the client who makes which of the following statements? a. I’m so glad to find out that this is only a plantarwart. I was afraid it was something contagious like athlete’s foot.
b. The health care provider will remove this plantar wart by first freezing it. c. I had a planter wart in the past that the health care provider removed with acid. d. The health care provider may remove my wart by burning it.
ANS: A 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.
PTS: 1 DIF: A REF: 856 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity /Basic Care & Comfort/Personal
- 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: a. Use a lot of friction when washing the feet to remove the dead skin cells b. Wash the client’s feet last to avoid spreading the athlete’s foot c. Leave the feet slightly damp after washing them to prevent further drying and cracking of the skin d. Apply the tolnaftate to the lesions on the client’s feet when she is done bathing the client
ANS: B 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.
PTS: 1 DIF: A REF: 856 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- 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? a. I need to see my podiatrist to have my toenails trimmed. b. I will inspect my feet daily using a mirror to see all areas. c. I should make sure my feet are thoroughly dry after my bath. d. I will wear antiembolus stockings when I get home to prevent my ankles from swelling.
ANS: D 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.
PTS: 1 DIF: A REF: 857 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal
- The nurse in a pediatrician’s 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? a. Isolate the child from their siblings until the child has been on antibiotics for at least 24 hours. b. Disinfect all the child’s toys. c. Wash all the child’s laundry in hot bleach water. d. Replace the child’s toothbrush.
PTS: 1 DIF: C REF: 885 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene
- 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.) a. Combing her hair b. Holding her toothbrush c. Wringing out the washcloth d. Rinsing with mouthwash e. Removing her wristwatch f. Wiping her face and neck
ANS: A, B, C, E 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.
PTS: 1
Chapter 40. Hygiene - Test Bank
Course: Fundamentals of Nursing (165)
University: University of California Los Angeles
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