Chapter 29: Hygiene

1.The nurse is working on a long-term rehabilitation unit, is providing care for a 46-year-old woman who was the victim of a violent crime and suffered a head injury. The patient has an endotracheal tube, which is secured with tape. The tape is crusted with dried secretions. The nurse is providing personal hygiene for the patient and needs to replace the tape. What is the best way for the nurse to remove the tape?

a.
Soak it with warm moist washcloths.
b.
Pull it gently away from the skin.
c.
Saturate it with denatured alcohol.
d.
Soak it with adhesive remover.

ANS: A

When patients have nasogastric, feeding, or endotracheal tubes inserted through the nose, change the tape, anchoring the tube at least once a day. When the tape becomes moist from nasal secretions, the skin and mucosa can easily become macerated (softened by soaking). Friction from a tube causes tissue injury. Anchor tubing correctly with tape or fixative devices to minimize tension or friction on the nares. Pulling away gently is preferred after soaking with warm moist clothes. Alcohol and adhesive remover are not recommended.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:773

OBJ: Correctly perform hygiene procedures for the care of the patient’s skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation

MSC:Client Needs: Management of Care

2.The student nurse caring for a 56-year-old patient with acquired immunodeficiency syndrome (AIDS). While providing oral care for the patient the student nurse notes that the gums are reddened and bleed easily. The student nurse identifies this as a sign of what condition?

a.
Dental caries
b.
Gingivitis
c.
Oral herpes
d.
Thrush

ANS: B

Gingivitis is inflammation of the gums, and dental caries is tooth decay produced by interaction of food with bacteria that forms plaque. Thrush is a yeast infection in the mouth and oral herpes are open sores in the mouth around the mucous membrane.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:748-749

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

TOP: Nursing Process: Assessment MSC: Client Needs: Basic Care and Comfort

3.A 25-year-old patient was admitted to the surgical floor wearing contact lenses. Assistive personnel ask the nurse if contact lenses need special attention. The nurse informs the assistive personnel that non–extended-wear contacts left in the eyes for an extended period of time can cause which of the following?

a.
Blindness
b.
Corneal injury
c.
Otitis externa
d.
Otitis media

ANS: B

Corneal injury can occur in patients who leave their contacts in for an extended period of time. Patients are admitted to hospitals or agencies in unresponsive or confused states. Remove contact lenses, and rinse lenses and eyes with a sterile saline solution. Physical limitations create inability to safely insert or remove contact lenses or to cleanse the lenses. Contact lenses cannot cause blindness, otitis externa, or otitis media.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:772

OBJ: Correctly perform hygiene procedures for the care of the patient’s skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation

MSC:Client Needs: Reduction of Risk Potential

4.A 45-year-old woman with diabetes who has been hospitalized with diabetic ketoacidosis. Which of the following is most important for the nurse to assess during bath time?

a.
Skin bruising
b.
Condition of teeth
c.
Sensation to the foot
d.
Skin folds for dirt

ANS: C

Assess patients with diseases that affect peripheral circulation and sensation for the adequacy of circulation and sensation of the feet. Palpate the dorsalis pedis and posterior tibial pulses and assess for intact sensation to light touch, pinprick, and temperature. Foot ulceration is the most common single risk factor for lower extremity amputations among persons with diabetes. The other responses are necessary to assess but not the highest priority for this patient with a diabetic diagnosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:754

OBJ:Explain the importance of foot care for the patient with diabetes.

TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

5.A nursing student who is working on a postsurgical unit assisting patients with personal hygiene plans to provide a back rub to each of her patients. The nursing student discusses the importance of this activity because research demonstrates that it enhances patient comfort and relaxation with the nurse assigned to these patients. The nurse instructs her that back rubs would be contraindicated on which of the following patients?

a.
A 56-year-old patient with a colon resection
b.
A 45-year-old patient with a spinal cord injury
c.
A 67-year-old patient with an appendectomy
d.
A 24-year-old patient with an abdominal hysterectomy

ANS: B

Consult a patient’s record for any contraindications to a massage such as spinal cord injury, rib fractures, or other painful conditions. Research shows that slow-stroke back massages of 3 minutes duration and hand massages of 10 minutes significantly improve both physiological and psychological indicators of relaxation in older persons. Always ask whether a patient would like a back rub or if he or she prefers gentle instead of deep massage because some patients dislike physical contact.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:771

OBJ:Perform a comprehensive assessment of a patient’s hygiene needs.

TOP: Nursing Process: Planning MSC: Client Needs: Basic Care and Comfort

6.A nurse who works for a pediatric clinic is preparing a 13-year-old patient with strep throat for the health care provider. Which of the following is the most important patient teaching information to prevent re-infection?

a.
“Replace your toothbrush.”
b.
“Floss thoroughly after each meal.”
c.
“Store your toothbrush with a toothbrush cover.”
d.
“Gargle with antiseptic mouthwash.”

ANS: A

Instruct patients to obtain a new toothbrush every 3 months or after a cold or strep throat to minimize growth of microorganisms on the brush surfaces. Avoid using toothbrush covers, which can create a moist enclosed environment that promotes bacterial growth. Dental flossing removes plaque and tartar between teeth. Instruct patients that flossing once a day is recommended. When teaching patients about mouth care, recommend that they not share toothbrushes with family members or drink directly from a bottle of mouthwash. Cross-contamination occurs easily. Antiseptic mouthwash is recommended for general use, but does not have an effect on the reinfection of strep.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 764 OBJ: Describe factors that influence personal hygiene practices.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

7.The nursing assistive personnel (NAP) has been delegated the task of changing a postsurgical patient’s bed. The NAP miscalculated the amount of linen needed and took more than needed. What is the best thing for the NAP to do with the unused linen?

a.
Replace it in the linen closet.
b.
Leave it in the room on the bedside table.
c.
Use it in another patient’s room.
d.
Place it in a laundry bag to be laundered.

ANS: D

Because of the importance of cost control and prevention of infection transmission, avoid bringing excess linen into a patient’s room. Once you bring linen into a patient’s room, even if the linen is not used, it must be laundered before being used by another patient. Do not place back into the linen area or use in another patient’s room. Excess linen lying around a patient’s room creates clutter and obstacles for patient care activities.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 779 OBJ: Make an occupied and unoccupied hospital bed.

TOP:Nursing Process: Implementation

MSC:Client Needs: Safety and Infection Control

8.A student nurse is bathing a patient with right lower lobe pneumonia. The student nurse is concerned with maintaining the patient’s dignity, warmth, and safety. Which of the actions will prevent the spread of microorganisms?

a.
Use superfatted soap.
b.
Wash from the cleanest to the contaminated body part.
c.
Use gloves when washing the patient’s face.
d.
Moving the call light out of reach of the patient to prevent it from becoming wet.

ANS: B

Always perform hygiene measures moving from the cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Use of superfatted soap will prevent skin breakdown. Use of gloves when washing the patient’s face decreases the patient’s dignity. For safety, the patient should have access to the call light at all times.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:781

OBJ: Correctly perform hygiene procedures for the care of the patient’s skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation

MSC:Client Needs: Safety and Infection Control

9.A student nurse is caring for four patients in her senior clinical rotation. The patients are scheduled for baths that include washing their hair. Which of the patients will the student nurse need a health care provider’s order to shampoo the hair?

a.
A 56-year-old man with diabetic ketoacidosis
b.
A 45-year-old woman with a neck injury
c.
A 34-year-old man with facial laceration
d.
A 67-year-old woman with pneumonia

ANS: B

You will need a health care provider’s order to shampoo the hair of patients with neck injuries. In situations in which bending is limited, teach the patient and family caregivers the degree of bending allowed. Assessment of the patient’s activity tolerance and balance should be assessed before washing the hair to determine the best mode to complete the activity. There is no need for a specific order in patients who are a diabetic, have pneumonia, or have facial lacerations.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:773 | 775

OBJ:Perform a comprehensive assessment of a patient’s hygiene needs.

TOP: Nursing Process: Assessment MSC: Client Needs: Management of Care

10.The nurse is caring for a 64-year-old patient who is hospitalized after surgery for a left total knee replacement. While preparing the patient’s personal care items for oral care, the patient states, “I have noticed a lot of plaque formation between professional teeth cleanings.” Which of the following foods would the nurse suggest to help reduce plaque formation?

a.
Soda
b.
Whole grain breads
c.
Citrus fruits
d.
Processed sugar snacks

ANS: C

Teach a patient that diet influences plaque formation and development of dental caries. Acidic fruits in the patient’s diet will reduce plaque formation. To prevent tooth decay, patients sometimes need to change eating habits (e.g., reducing intake of carbohydrates, consumption of soda, and especially sweet snacks between meals).

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 764 OBJ: Describe effect of oral hygiene on periodontal disease.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

11.The health care provider orders meticulous foot care on a patient with diabetes. What is the best rationale for the nurse to assess the patient for complications?

a.
Poor hygienic practices in patients with diabetes
b.
Vascular changes, which reduces circulation
c.
The aging process, which causes skin breakdown and ulceration
d.
Limited joint range of motion, which makes caring for feet difficult

ANS: B

People with diabetes develop many different foot complications associated with nerve damage and poor blood flow to the lower extremities. Foot injuries in the patient with diabetes can quickly turn into a serious problem with slow healing, infection, and the possibility of amputation. According to the American Diabetes Association (2012a) more than 60% of lower limb amputations for nontraumatic reasons are associated with diabetes. If a patient has diabetes or any other condition affecting peripheral circulation or sensation, recommend a podiatrist for regular examinations and trimming of nails. Also instruct these patients to report any of the following to their health care provider: abnormalities or changes in the nail, including changes in nail shape or color; bleeding around the nails; thinning or thickening of the nails; redness, swelling, or pain around the nails. Poor hygienic practices, the aging process, and limited movement are all good reasons to assess the foot of a diabetic patient, but because of the specific complications related to the vascular changes that occur with diabetes, this is the best rationale to assess for complications.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:764 | 765

OBJ:Explain the importance of foot care for the patient with diabetes.

TOP:Nursing Process: Assessment

MSC:Client Needs: Reduction of Risk Potential

12.An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first do which of the following?

a.
Assess the patient for a gag reflex.
b.
Position the patient in a prone position.
c.
Have an operational suction machine nearby.
d.
Retract the upper and lower teeth with a padded tongue blade.

ANS: A

If the patient does not have a gag reflex he or she is at an increased risk of aspiration. If no gag reflex is present two people may be needed, one to perform oral care and the other to suction the patient’s mouth to prevent aspiration of fluid. The prone position is face down, which is not the position of choice. After you check for the gag reflex, a suction machine is necessary to remove secretions. A padded tongue blade is used to hold the mouth open.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:768

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

TOP:Nursing Process: Implementation

MSC:Client Needs: Reduction of Risk Potential

13.A patient requires toenail care. While the nurse performs nail care and nail care education the patient is instructed to always do which of the following?

a.
Use clippers or manicure scissors to trim the nails straight across.
b.
Apply a hot water bottle to the feet before foot care to soften the tissues.
c.
Apply over-the-counter preparations to any foot fungus or disease.
d.
Apply moist wet-to-dry dressing on any cuts and cover with socks.

ANS: A

Demonstrate proper trimming and filing techniques. For ongoing home care, instruct patients or their family caregivers to use sharp manicure scissors or clippers to trim the nails straight across, then round the tips by filing in a gentle curve. Explain that trimming is easiest when the nails are soft, such as after a bath, but be sure the nails have dried before filing to prevent splitting. Never recommend soaking the nails if a person has diabetes. Applying a hot water bottle, over-the-counter preparations, and moist wet-to-dry dressing are not standard during foot care.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:764 | 765

OBJ: Correctly perform hygiene procedures for the care of the patient’s skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Nursing Process: Implementation

MSC:Client Needs: Basic Care and Comfort

14.The nursing student is caring for a patient with a hearing aid. The nursing student sees that the patient has taken out his or her hearing aid and set it on the windowsill. What should be the nursing student’s next intervention?

a.
Remove the battery from the hearing aid because it is not in use.
b.
Cover the hearing aid with a lint-free cloth to protect it from the heat.
c.
Remove the hearing aid from the windowsill because heat can change the shape of the ear mold, causing the appliance not to fit properly.
d.
Remind the patient to put the hearing aid back in before meals.

ANS: C

Do not store the aid in a warm place such as a windowsill or in a car. The heat can change the shape of the ear mold, causing the aid to not fit properly. Remove the battery from the hearing aid when it is not being used for a day or longer. Avoid dropping the aid or twisting the cord. Remove the aid before radiological examination or radiation therapy to avoid damage. Protect the aid from water, alcohol, aerosol sprays, perspiration, and cologne. Use the manufacturer-recommended cleaning solution and a soft, lint-free cotton cloth to clean the ear mold.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:777

OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp and their related interventions. TOP: Nursing Process: Implementation

MSC:Client Needs: Reduction of Risk Potential

15.Older adult patients produce less sebum and perspire less than younger patients. Therefore when providing personal hygiene the nurse should do which of the following?

a.
Use hot water and regular soap.
b.
Use plain water and a soft towel.
c.
Provide a total bed bath every day.
d.
Use warm water and a mild cleansing agent.

ANS: D

Older patients’ skin is more fragile; therefore avoid hot water (warm water is preferred) and use a mild cleansing agent. Some authorities suggest using bath oils; however, this increases the danger of falling in a slippery tub. Advise against the use of hot water for bathing as well as too lengthy bathing sessions to prevent loss of oils and excessive drying of skin. Also encourage patients to consume a balanced diet including foods rich in antioxidants, vitamins, and minerals, and to consume adequate fluids. Stress safety concerns in the home such as failure to adjust the water temperature when bathing or showering or slipping on wet surfaces in the bathroom.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:777

OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Adaptation

16.A patient is non–English speaking and unable to answer questions. When preparing to bathe this patient the nurse needs to remember which of the following?

a.
Use soaps which contain deodorant to help control body odor.
b.
Cultural heritage influences hygiene practices.
c.
Shave facial hair to make the patient more presentable.
d.
Diaphoresis will prevent skin breakdown and infection, so the patient should only be bathed once a day.

ANS: B

A patient’s cultural beliefs and personal values influence hygiene care. Maintaining cleanliness may not have the same importance for some ethnic groups as it does for others. In some cultures, it is customary to completely bathe only once a week. Never shave facial hair or hair without the patient’s permission. Use only mild cleansers; avoid deodorant bars, perfumed soaps, and any products with alcohol. Clean the skin at the time of any soiling and at routine intervals. Problems such as incontinence, wound drainage, or excessive diaphoresis require more frequent cleansing to promote comfort and prevent skin breakdown and infection.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 766 | 777 OBJ: Describe factors that influence personal hygiene practices.

TOP: Nursing Process: Implementation MSC: Client Needs: Basic Care and Comfort

17.A bedridden patient with long hair may experience problems with matting. What is the most appropriate nursing action?

a.
Cut the matted hair away.
b.
Braid the hair to reduce the tangles.
c.
Use a thick, commercial product to grease the hair.
d.
Keep the hair dry by applying powder every morning.

ANS: B

Braiding helps to avoid repeated tangles. Ask permission before braiding or cutting a patient’s hair. Do not apply powder every morning. Moistening the hair with water or an alcohol-free detangle product makes the hair easier to comb.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:773

OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp and their related interventions. TOP: Nursing Process: Implementation

MSC:Client Needs: Basic Care and Comfort

18.Which of the following interventions will decrease the chance of dry skin?

a.
Daily baths in a soaker tub for 30 minutes
b.
Inadequate fluid and nutrition
c.
Leave moisturizing soap on the body
d.
Use of superfatted soap

ANS: D

To minimize drying of the skin use warm, not hot, water and use superfatted soap (e.g., Dove) for cleansing. Effective treatment of dry skin does not require limiting frequency of bathing. Bathing daily for limited time (10 minutes or less) can assist with hydration. Rinse body of all soap well because residue left can cause irritation and breakdown. Use a humidifier to add moisture to air. Increase fluid intake when skin is dry. Use moisturizing lotion to aid healing process; lotion forms protective barrier and helps maintain fluid within skin.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:755

OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

19.The nurse is caring for a patient who is on a heparin drip for a deep vein thrombosis (DVT). During the bath, the nurse will wash the lower extremities using which of the following?

a.
Circular motion to massage the legs
b.
Long, firm strokes toward the heart
c.
Short, firm strokes toward the heart
d.
Short, light strokes

ANS: D

In a patient with a current DVT, light short strokes are recommended. Because of the risk of dislodging a deep vein thrombosis, do not use long, firm strokes to wash the lower extremities of patients with a deep vein thrombosis or blood-clotting disorder. Use short, light strokes instead. Avoid massaging the legs.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:786

OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

20.The nurse is assigned to assist a 59-year-old woman who has suffered a stroke and has limited mobility. The nurse is performing perineal care and understands that the best way to prevent disease transmission to the perineum is that it should be cleaned:

a.
from the rectal area to the urinary meatus.
b.
from the urinary meatus to the rectal area.
c.
in a circular motion.
d.
only twice a day.

ANS: B

Perineal care involves thorough cleansing of the patient’s external genitalia and surrounding skin. Skin folds may contain body secretions that harbor microorganisms. Wiping front to back reduces chance of transmitting fecal organisms to urinary meatus. Cleaning from the rectal area to the urinary meatus or in a circular motion is incorrect because this will cause cross contamination with urine, drainage or feces.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:786 | 787

OBJ: Describe how hygiene for an older adult differs from that for a younger patient.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance