Ch.24 Hygiene & Self Care

Question 1

Which health problem is most clearly suggestive of a history of inadequate dental care?

Answer 1

Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene

Question 2

Chelosis

Answer 2

Indicative of vitamin deficiency

Question 3

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Answer 3

Dry the cleaned areas and apply an emollient as indicated

When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination

Question 4

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

Answer 4

A traditional bed bath with linen change provides the greatest opportunity for full cleansing. The client is unable to perform assistance with a shower, and is not a candidate for a bed bath. Although a bag bath may be useful, the traditional bed bath with linen change provides the best opportunity for infection control in observance of the mild skin breakdown that has been noted.

Question 5

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

Answer 5

The client should be placed in a side-lying position to prevent aspiration.
Clients who are not alert are at risk for aspirating liquid into their lungs. Aspirated fluids predispose a client to pneumonia. The nurse should use special precautions to avoid getting fluid into the client’s airways and lungs.
Position the client on the side with the head slightly lowered. An upright position will not protect the airway from fluids entering.

Question 6

Corn

Answer 6

A cone shaped lesion over the 4th or 5th toe

Question 7

Plantars wart

Answer 7

a round or irregular area that is flattened by pressure and is surrounded by cornified epithelium

Question 8

Bunion

Answer 8

an inflammation and thickening of bursa at the great toe joint which causes an enlargement of the joint and a displacement of the toe.

Question 9

Callus

Answer 9

a flattened thickening of epidermis which is often found on the bottom or side of the foot, over a bony prominence

Question 10

Which client is most at risk for foot difficulties?

Answer 10

People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes.

Question 11

RN duties

Answer 11

wound care and assessments

Question 12

UAP duties

Answer 12

back massage, bathing

Question 13

A nurse is educating a client on how to care for their dentures. What is a recommended teaching guideline?

Answer 13

Store dentures in cold water when not in use
Encourage the client to wear her dentures, if not contraindicated. Dentures enhance appearance, assist with eating, facilitate speech, and maintain the gum line. Denture fit may be altered if dentures are not used for long stretches. Encourage the client to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. Encourage the client to refrain from placing the dentures in the bed clothes because they can be lost in the laundry. Store dentures in cold water when not in the client’s mouth. Leaving dentures dry can cause warping, leading to discomfort when worn (

Question 14

The nurse is observing the client’s ability for self-care and bathing while the client is in the bathroom. The client states, “Oh 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?

Answer 14

The hot water tank thermostat should be set below 120°F to avoid burns during bathing.

Question 15

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

Answer 15

An adolescent’s skin ordinarily has enlarged sebaceous glands and increased glandular secretions which predisposes them to acne.

Question 16

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?

Answer 16

Eroding the tooth enamel can cause dental caries (cavities)

Question 17

Tartar

Answer 17

hard to remove and can lead to gingivitis (inflammation of the gums)

Question 18

Periodontal disease

Answer 18

promoted by pockets of gum inflammation

results in the destruction of the tooth-supporting structures and bones that make up the jaw.

Question 19

Which is an internal resource that the client has to help her attain her self-care goals?

Answer 19

She has motivation to participate in self-care

An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

Question 20

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?

Answer 20

Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults

Question 21

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?

Answer 21

The client needs education about why bathing is important. Knowledge deficit, and fear of loss of independence and/or privacy, may be impacting the client’s choice. The nurse will first provide information about the reason that bathing is important, and then assure the client that privacy will be maintained, empowerment will be given, and autonomy will be respected.

Question 22

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Answer 22

Store the hearing aid in cool environment.

Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Other items listed are inappropriate for teaching.

Question 23

An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident’s hygiene needs while preventing skin dryness?

Answer 23

Use a nonsoap cleaning agent.

Soap cleans the skin, but while it removes dirt from the surface, it affects the lipids that are present on the skin, and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. T

Question 24

xerostomia

Answer 24

caused by decreased saliva production. The oral mucosa in the older adult tends to become drier as saliva production lessens. This is called xerostomia and is caused by many factors, most commonly as a side effect of medications.

Question 25

Which nursing action is appropriate when providing foot care for a client?

Answer 25

Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin.

Question 26

partial care

Answer 26

receive morning care at the bedside, or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

Question 27

complete care

Answer 27

require nursing assistance with all aspects of personal hygiene

Question 28

self care

Answer 28

capable of managing their personal hygiene independently once oriented to the bathroom

Question 29

Sitz Bath

Answer 29

Used to relieve discomfort and pain

Question 30

What is a correct guideline to follow when providing a bed bath for a client?

Answer 30

Fold the washcloth like a mitt on your hand so that there are no loose ends.
The gluteal area should be cleaned first and the bath water and towels should be changed before cleaning the perineal area

Question 31

Bag Baths

Answer 31

A bag bath does decrease the risk of skin breakdown due to the lubricating cleanser. A bag bath does reduce the spread of microorganisms and does promote comfort by maintaining warmth. While the bag bath does save time, it is not a therapeutic response to the client and bag baths do not promote skin friction they reduce friction.