Chapter 29: Hygiene

Chapter 29: Hygiene

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

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?

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:    1                      DIF:    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?

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?

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:    1                      DIF:    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?

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:    1                      DIF:    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