Chapter 24. Hygiene

Chapter 24. Hygiene

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1. The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient’s care plan? Teach the patient to:

1)      use an electric razor for shaving.

2)      apply skin moisturizer.

3)      use less soap when bathing.

4)      floss teeth daily.

 

ANS:   1

The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

 

PTS:    1                      DIF:    Easy                REF:    p. 702

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____    2.         The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?

1)

Avoid bathing the patient.

2)

Use cool water for bathing.

3)

Provide care in small intervals.

4)

Rub briskly when towel drying.

 

ANS:   3

The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

 

PTS:    1                      DIF:    Difficult          REF:    pp. 685-686 – answer is not expressly given.

KEY:   Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

 

 

 

____    3.         A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem?

1)

Total Self-care Deficit

2)

Bathing/Hygiene Self-care Deficit

3)

Dressing/Grooming Self-care deficit

4)

Activity Intolerance

 

ANS:   2

The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patient’s inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario.

 

PTS:    1                      DIF:    Moderate        REF:    ESG, Chapter 24, “Standardized Language,” Table: “Selected Standardized Outcomes and Interventions for Self-Care”

KEY:   Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level: Analysis

 

 

 

____    4.         Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax?

1)

Afternoon care

2)

Early morning care

3)

Morning care

4)

Hour of sleep care

 

 

ANS:   4

The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation. During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing. Early morning care typically consists of assisting with toileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and hair care. It may also include dressing and positioning or assisting the patient to the chair.

 

PTS:    1                      DIF:    Easy                REF:    p. 687

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

 

 

 

____    5.         For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.

1)

32-year-old admitted with a closed head injury

2)

76-year-old admitted with septic shock

3)

62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

4)

23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

 

ANS:   3

Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

 

PTS:    1                      DIF:    Difficult          REF:    p. 687

KEY:   Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis