Chapter 27: Hygiene and Personal Care Answers for Review Questions 1. An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. “Do you have friends or family nearby?” b. “Can you raise your arms up to brush your teeth?” c. “Do you become short of breath during your shower?” d. “Are you able to get in and out of your bed at home?” Answer: c Knowing the COPD patient’s activity tolerance helps the nurse formulate a plan for ongoing hygiene care in the hospital and after discharge. Having friends and family nearby may be helpful, but until the activity tolerance is known, his need for outside assistance is not known. A complete assessment of physical capabilities, including his ability to brush his teeth and whether he can get in and out of bed, is important after his activity tolerance has been assessed. LO: 27.3 Bloom’s: Analyzing NCLEX Client Needs: Physiological Integrity: Personal Hygiene 2. Which action by a female patient lets the nurse know the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. Copyright © 2023 by Elsevier, Inc. All rights reserved. d. The patient washes her perineum lightly to prevent tissue damage. Answer: b The female perineum is always washed from front to back, washing the area near the urinary meatus first and working back to the anus to avoid introducing organisms into the urinary tract. A circular motion is used for a male patient, washing around the urinary meatus first and then washing down the shaft of the penis. Firm strokes can be used so that the area is well cleaned. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Personal Hygiene 3. The nurse on a medical floor in a hospital just completed a bed bath. The nurse should take what action before leaving the patient’s room? a. Place the call light within reach so the patient can call for help if needed, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach. Answer: c The bed is always left in the lowest position so that it is closer to the floor. The top two side rails aid the patient in turning and positioning. The call light is placed within reach of the patient so that the nurse can be called if needed. Leaving the bed in a working or higher position increases Copyright © 2023 by Elsevier, Inc. All rights reserved. the danger of falling if the patient tries to get out of bed. Raising all four side rails is considered a restraint. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention 4. Which actions by the nurse concerning oral care for an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush Answer: b, c, d Oral care on an unconscious patient is performed with the patient turned to one side so that fluid can drain out of the side of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should be provided at least every 2 hours for patients who are unconscious, receiving nothing by mouth (NPO), intubated, or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done in the supine position. A hard-bristle brush may damage the oral mucosa. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Personal Hygiene Copyright © 2023 by Elsevier, Inc. All rights reserved. 5. Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bath Answer: b The patient with peripheral neuropathy may not be able to distinguish extremes of hot and cold. To prevent burns from extremely hot water, the nurse checks the water temperature before beginning the bath and each time clean water is obtained. It is important to keep the top two side rails up when not at the bedside to facilitate turning and positioning. Facilitating range-of-motion exercises and as much independence as possible is important for all patients rather than being a specific safety concern for the patient with peripheral neuropathy. Dangling is important to implement with patietns who have been bedridden and may experience orthostatic hypotension. LO: 27.2 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Basic Care and Comfort 6. Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Lack of Knowledge c. Activity Intolerance d. Able to Perform Self-Care Copyright © 2023 by Elsevier, Inc. All rights reserved. Answer: a A patient who has an impaired ability to complete bathing, mouth care, toileting, grooming, dressing, and eating without assistance has a Self-Care Deficit. Lack of Knowledge implies that the patient does not have certain information. Activity Intolerance may be a concern if a patient’s level of activity is reduced, but this nursing diagnosis is not necessarily related to needing assistance. A diagnosis of Able to Perform Self-Care means that the patient is ready to perform activities to enhance health. LO: 27.4 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Management of Care 7. Which statements are true regarding back massage? (Select all that apply.) a. Only a licensed massage therapist can perform back massage. b. Back massage may stimulate the deep muscles. c. Massage provides relaxation and comfort. d. Tapotement stimulates the skin. e. A massage may promote sleep. Answer: b, c, d, e Back massage provides relaxation, increases circulation, stimulates the skin and deep muscles, and promotes sleep. Nursing personnel can perform a back massage during care, before bedtime, or any other time to help the patient relax. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Basic Care and Comfort Copyright © 2023 by Elsevier, Inc. All rights reserved. 8. A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement should the nurse include with teaching about this shampoo? a. It can be used only on patients with the ability to stand in the shower. b. It can cause central nervous system side effects, including dizziness. c. It is used by pregnant women and young children. d. It is safe for patients with seizures or epilepsy. Answer: b Pediculicidal shampoos can have central nervous system side effects, including dizziness, headache, and seizures. Their use is contraindicated for patients with a history of seizures and for pregnant women and young children. LO: 27.6 Bloom’s: Understanding NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control 9. Which statement indicates an understanding by the unlicensed assistive personnel of eye care during a patient’s bath using washcloths and a bath basin? a. “The eyes are washed with soap and water from the inner canthus to the outer canthus.” b. “The eyes should always be washed using sterile normal saline and a gauze sponge.” c. “The eyes are washed from the outer canthus to the inner canthus using water only.” d. “The eyes are washed with water using a clean part of the washcloth for each eye.” Answer: d Copyright © 2023 by Elsevier, Inc. All rights reserved. Eyes are washed with water only from the inner canthus to the outer canthus to prevent the spread of pathogens into the tear ducts. A clean section of the washcloth is used for each eye to avoid cross-contamination. Soap is irritating to the eye and is therefore contraindicated. It is unnecessary to use sterile saline for routine cleansing of the eye. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Basic Care and Comfort 10. A new patient is assigned to the unit. When attempting to provide personal care for the patient, which patient-centered care needs should the nurse consider? (Select all that apply.) a. Age b. Skin condition c. Transportation concerns d. Patient’s feelings and wishes e. Time constraints f. Religious beliefs g. Cultural tradition h. Disability restrictions i. Admission complaint Answer: a, b, d, f, g, h The nurse must consider diversity when providing patient-centered care in order to provide care that addresses the patient’s needs. This includes cultural, ethnic, religious, and personal preferences of the patient as well as patient specific characteristics noted by the nurse during Copyright © 2023 by Elsevier, Inc. All rights reserved. assessment. The nurse’s time constraint, admission complaint, and transportation needs should not interfere with the thoroughness of care provided. LO: 27.6 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Basic Care and Comfort Copyright © 2023 by Elsevier, Inc. All rights reserved.
