Prep U: Chapter 23
Which clent would be at greatest risk for injury to the skin and mucous membranes?
man 77 years of age with diabetes
A nurse is providing oral care to a client with dentures. What action would the nurse do first?
Upon review of the client’s orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene?
Provide the client with an electric shaver.
A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving, which of the following would be most important?
Shaving in the direction of hair growth
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
Medications listed on the clients MAR
A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made?
The head for nits on hair shafts
Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?
A nurse is making a bed occupied by a patient. Which of the following is a recommended step for this procedure?
Fan-fold soiled linens as close to patient as possible.
A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care?
Middle-age woman with a Foley catheter
A nurse is caring for a client with a fractured arm. As part of hair care, what should the nurse do to increase circulation and distribution of sebum in the client’s hair?
Brush the client’s hair slowly.
When providing oral care, which of the following does the nurse recognize as the most important component of the oral care process?
A thorough mechanical cleaning
A client who has started using contact lenses visits a health care facility with an eye infection. The nurse observes that the client also has an eye abrasion. Which of the following could be the possible reason for the eye infection?
contact lenses were not cleaned
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse’s first action will be to assess the child for the presence of which of the following?
Older, continent patients who are hospitalized should receive a full bed bath with soap and water every day.
The nurse is making a home visit to an older adult client recently discharged from the acute care facility after surgery. The nurse is observing the client’s ability for self-care and bathing while the client is in the bathroom. The client states, “My this hot water seems really hot.” The nurse instructs the client and spouse to check the water heater thermostat to ensure that the temperature is below which temperature?
120 degrees F
An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident’s hygiene needs while preventing skin dryness?
Use a nonsoap cleaning agent.
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?
A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do?
Provide supplies and assist with hard-to-reach areas.
A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following?
Facilitates oil distribution
The mother of a child 2 years of age tells the nurse she always cleans the child’s ears with a hairpin. What would the nurse tell the mother?
“That is dangerous; you might puncture the eardrum.”
A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client’s medical record?
A nurse is assessing the client’s ability to perform ear care. Which statement by the client requires further teaching by the nurse?
“I use cotton-tipped applicators daily to remove cerumen.”
A nurse is shaving the facial hair of a bed-ridden patient. Which of the following is a recommended guideline for this procedure?
Shave with the direction of hair growth in downward, short strokes.
An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of bathing/hygiene: self-care deficit. What would the priority nursing intervention be?
Assess the client’s cultural views regarding hygiene and self-care.
A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which of the following statements describes this phase of the wound repair process?
Period during which new cells fill and seal a wound
Which of the following health problems is most clearly suggestive of a history of inadequate dental care?
The nurse is caring for a female client who is unconscious. You should pay special attention to cleaning which of the following areas of the body?
Underneath the breasts and in between skin folds
A patient tells a nurse that he always uses boric acid solution to wash out his eyes. What would the nurse teach the patient?
“Boric acid should not be used; it is toxic when absorbed.”
A client is able to transfer out of bed to a chair but is unable to walk to the bathroom. Which of the following would be most appropriate for the nurse to use when assisting this client with elimination?
Which client is most likely to require hospitalization related to problems associated with the feet?
A client with peripheral vascular disease
A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do?
Wash hair daily
A nurse working in a clinic for older adults is providing care to a client receiving treatment for xerostomia. The nurse interprets this condition as which of the following?
decreased saliva production
The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client’s entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct?
Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place
What physical changes during adolescence predispose the adolescent to body odor and acne?
A nurse is asked to wash the hair of a patient who has a spinal cord injury. Which of the following is a guideline that the nurse should follow when performing this procedure?
Use a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container.
Which of the following is a correct guideline to follow when providing a bed bath for a client?
Fold the washcloth like a mitt on your hand so that there are no loose ends
Which client would be most at risk for alterations in oral health?
Man with a nasogastric tube
A nurse is teaching a patient how to care for her dentures. Which of the following is a recommended teaching guideline?
Store dentures in cold water when not in use.
Bathing should be performed in an orderly, head-to-toe manner.
A nurse is washing a patient’s hair using a shampoo cap. Which of the following is an accurate step in this procedure?
Remove and discard the cap and dry the hair with a towel.
For which of the following patients would the use of a flannelette blanket as a bottom sheet be recommended?
An elderly person with arthritis.
An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client’s dentures?
Store the client’s dentures in water when the client is not wearing them.
While performing a physical examination of a client who is in a coma, the nurse finds that the client has dandruff. Which of the following would be most appropriate for the nurse to apply to the client’s hair to manage dandruff?
A middle-aged client who wears glasses and has a slight hearing problem needs a hearing aid that is small and not too expensive. Which of the following hearing aid devices is best suited for the client?
A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which of the following clients is most susceptible to nail problems?
Clients with diabetes
A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care?
Use an anti fungal powder on the clients feet if necessary
An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin?
activity of the glands in the skin lessens
While conducting an oral assessment, a nurse notices the client’s gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate?
A nurse is caring for a female client with diarrhea. What instruction should the nurse give the client with regard to perineal hygiene?
Clean the perineal area from the front to back
When shaving a male patient’s face, pull the skin taut and use short, upward strokes.
Which of the following statements accurately describes a recommended step when making an unoccupied bed?
Loosen all linen as you move around the bed, from the head of the bed on the far side to the head of the bed on the near side.
In order to maintain a healthy and hygienic integumentary system, a nurse is clipping the overgrown nails of an older adult client. Which other part should the nurse check to maintain the hygiene of the client’s integumentary system?
Which is one of the most important benefits of a nurse helping with bathing?
nurse client relationships are facilitated
A nurse assists a patient to clean his dentures. Which of the following is an accurate step in this process?
insert upper denture in mouth and press firmly, then insert lower denture
A home care nurse visits a client for follow up. During the visit, the client asks the nurse to explain the process for cleaning the soft contact lenses that he got recently. Which of the following would the nurse include when teaching the client about contact lens care?
Rinse with cleaning solution to remove debris
A nurse is planning the discharge for an older adult client with Parkinson’s disease. Which of the following activities would the nurse observe to assess the client’s fine motor skills?
applying make up
A nurse is discussing care of her four clients with an unlicensed assistive personnel (UAP). The UAP is planning morning care and hygiene for the clients. Which client should the nurse instruct the UAP to offer hygiene measures to first?
A pleasantly confused 86 year old female requiring partial care being discharged today
A nurse is caring for a client with hemorrhoids. The physician has ordered sitz baths for the client twice a day. Which of the following would the nurse do when giving a sitz bath?
Ensure that the pelvic region is immersed in the water