CHAPTER 27: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 27: Hygiene and Personal Care Multiple Choice Questions 1. The nurse knows that which statement is true regarding the importance of hygiene? A. The nurse can assess other body systems during the bath. B. UAPs perform hygiene because there is no benefit of nurses doing this care. C. The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. D. The main purpose of bathing is to decrease the patient's body odor. Answer: A Explanation: Bathing provides an opportunity to assess multiple body systems, such as skin integrity, circulation, and mobility, while also promoting comfort and hygiene. Why Other Options Are Wrong: B overlooks the nurse's role in assessment during hygiene care. C is incorrect because mucous membranes are part of the integumentary system. D understates the broader purposes of bathing, including skin health and assessment. 2. Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable Nursing diagnosis for a patient with excessively dry skin? A. Impaired Health Maintenance. B. Risk for Injury. C. Risk for Infection. D. Acute Pain. Answer: C Explanation: Dry, cracked skin compromises the body's first line of defense, increasing susceptibility to infections. Why Other Options Are Wrong: A is too broad and not specific to infection risk. B focuses on injury rather than infection. D is unrelated to the primary risk of skin breakdown. 3. The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing? A. Patient with asthma. B. Patient with attention deficit hyperactivity disorder. C. Patient with a stroke. D. Patient with diabetes. Answer: D Explanation: Diabetic neuropathy impairs temperature sensation, increasing the risk of burns or injury from water extremes. Why Other Options Are Wrong: A and B do not involve sensory deficits. C may have unilateral sensory loss but is less at risk than diabetes. 4. Which tool is used by the nurse to determine risk for impaired skin integrity? A. Braden scale. B. Glasgow scale. C. Vanderbilt scale. D. MMSE scale. Answer: A Explanation: The Braden scale assesses factors like moisture, activity, and nutrition to predict pressure ulcer risk. Why Other Options Are Wrong: B evaluates coma severity, C assesses behavior, and D measures cognitive function. 5. The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one? A. Patient will ambulate independently within a day. B. Patient will perform all own ADLs. C. Patient will consume 75% of all meals. D. Patient will begin to perform 25% of own ADLs. Answer: D Explanation: Starting with 25% of ADLs is realistic and promotes gradual independence post stroke. Why Other Options Are Wrong: A and B are overly ambitious for day one. C addresses nutrition, not self-care. 6. The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first? A. Hands. B. Eyes. C. Face. D. Arms. Answer: B Explanation: Eyes are bathed first without soap to prevent irritation, followed by face, hands, and arms. Why Other Options Are Wrong: A, C, and D are cleaned after the eyes to maintain hygiene sequencing. 7. The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate? A. To promote circulation. B. To maintain asepsis. C. To maintain comfort. D. To maintain tradition. Answer: A Explanation: Washing distal to proximal enhances venous return and circulation. Why Other Options Are Wrong: B refers to infection control, not circulation. C and D are irrelevant to the technique's purpose. 8. The nurse has assisted the patient to wash the hands, face, axillae, and perineal area. What type of bath does the nurse chart? A. Sink bath. B. Complete bed bath. C. Partial bed bath. D. Shower. Answer: C Explanation: A partial bath involves cleaning specific areas, unlike a complete bath or shower. Why Other Options Are Wrong: A involves a sink, B includes the entire body, and D requires patient mobility. 9. The nurse is performing perineal care for the uncircumcised patient. Which action does the nurse take? A. Does not move the foreskin. B. Retracts the foreskin, pulling it away from the body. C. Leaves the foreskin retracted, allowing it to return to position naturally after care. D. Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying. Answer: D Explanation: Retracting and returning the foreskin prevents constriction and swelling. Why Other Options Are Wrong: A neglects hygiene, B and C risk complications like paraphimosis. 10. Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient? A. Nurse. B. Physical therapist. C. Occupational therapist. D. Podiatrist. Answer: D Explanation: Podiatrists specialize in foot care for high-risk patients like diabetics. Why Other Options Are Wrong: A, B, and C lack the specialized training for diabetic foot care. 11. When providing the patient with routine hygienic care, which action would the nurse omit? A. Massage the back with lotion. B. Oral care with a toothbrush. C. Shaving with a disposable razor. D. Ear hygiene with cotton-tipped applicators. Answer: D Explanation: Cotton-tipped applicators can push wax deeper, risking impaction or injury. Why Other Options Are Wrong: A, B, and C are standard, safe hygiene practices. 12. The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care? A. High Fowler's. B. Prone. C. Side-lying. D. Low Fowler's. Answer: C Explanation: Side-lying prevents aspiration by allowing secretions to drain. Why Other Options Are Wrong: A, B, and D do not adequately protect against aspiration. 13. What action by the nurse is inappropriate regarding denture care? A. Carrying the dentures to the sink wrapped in a paper towel. B. Placing a towel in the sink and brushing the dentures over the towel. C. Brushing the dentures as the nurse would the teeth of a conscious patient. D. Applying adhesive, then inserting upper and then lower dentures. Answer: A Explanation: Dentures should be carried in a denture cup to avoid damage or loss. Why Other Options Are Wrong: B, C, and D are correct denture care practices. 14. What statement by the nurse is true regarding oral care of patients on anticoagulants? A. Use an electric toothbrush daily. B. Avoid oral care. C. Use mouthwash only. D. Use a soft-bristled toothbrush. Answer: D Explanation: Soft bristles minimize gum bleeding risk in anticoagulated patients. Why Other Options Are Wrong: A can cause trauma, B neglects hygiene, and C is insufficient. 15. The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next? A. Moisten the finger with lens solution and gently touch it to pick it up. B. Moisten the contact lens with tap water and pick it up. C. Pick it up and insert the contact lens. D. Discard the contact lens. Answer: A Explanation: Moistening with solution ensures safe retrieval and prevents contamination. Why Other Options Are Wrong: B introduces tap water contaminants, C risks infection, and D is unnecessary. 16. The nurse recognizes which statement by the patient indicates a teaching need? A. "I use bobby pins to remove excessive ear wax." B. "I use soap and a warm cloth to clean the outside of my ear." C. "My doctor sometimes gives me oil drops for my ears." D. "I never use Q-Tips." Answer: A Explanation: Bobby pins can perforate the tympanic membrane and are unsafe. Why Other Options Are Wrong: B, C, and D reflect appropriate ear care practices. 17. The nurse is asked to shave a patient who is taking warfarin (Coumadin). What is the most appropriate action? A. Refuse to shave the patient because he is on an anticoagulant. B. Shave as usual with a safety razor. C. Offer to wax rather than shave the patient. D. Use an electric razor. Answer: D Explanation: Electric razors minimize bleeding risk in anticoagulated patients. Why Other Options Are Wrong: A denies patient preference, B risks cuts, and C may not be feasible. 18. The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect? A. The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. B. The nurse rolls dirty linens to the side then places the linens on the floor while finishing. C. The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. D. The nurse wears gloves to remove dirty linens. Answer: B Explanation: Dirty linens should be placed in a hamper, not on the floor, to prevent contamination. Why Other Options Are Wrong: A, C, and D are correct bed-making practices. Multiple Response Questions 1. The nurse knows that which areas of the patient's body are at increased risk of excoriation? (Select all that apply.) A. Exposed areas such as the face. B. Areas exposed to stool. C. Skin on skin areas. D. Area under pendulous breasts. E. Under an abdominal fold. Answer: B, C, D, E Explanation: Excoriation occurs where skin is exposed to moisture or friction, such as under folds or near bodily fluids. Why Other Options Are Wrong: A is more prone to environmental damage like sunburn. 2. The nurse is demonstrating cultural sensitivity in performing perineal care when carrying out which actions? (Select all that apply.) A. The male nurse delegates perineal care of a female patient to the female UAP. B. The male nurse asks a female patient if she would prefer a female to perform care. C. The nurse approaches the care in a sensitive, professional manner. D. The nurse assesses cultural preferences of the patient prior to care. E. The nurse provides care quickly and in a matter of fact manner. Answer: B, C, D Explanation: Cultural sensitivity involves assessing preferences, offering choices, and maintaining professionalism. Why Other Options Are Wrong: A assumes preferences without asking. E may seem dismissive. 3. When the nurse is assisting patients with hygiene care, which tasks should be included? (Select all that apply.) A. Bathing. B. Oral care. C. Perineal care. D. Foot care. E. Patient communication. Answer: A, B, C, D, E Explanation: Hygiene care encompasses bathing, oral/perineal/foot care, and communication for assessment and comfort. Why Other Options Are Wrong: All options are correct and integral to hygiene care. 4. The nurse is bathing a patient and notes reddened skin above the coccyx. Which actions by the nurse are appropriate? (Select all that apply.) A. Apply a barrier cream and massage the area. B. Document the findings. C. Position the patient to relieve pressure on coccyx. D. Report the area to the charge nurse. E. Report the new finding to the provider. Answer: B, C, D, E Explanation: Reddened skin should be documented, pressure relieved, and reported to prevent further breakdown. Why Other Options Are Wrong: A is incorrect because massaging reddened areas can worsen tissue damage. 5. Regarding perineal care, which nursing actions are appropriate? (Select all that apply.) A. The nurse applies gloves prior to performing perineal care. B. The nurse ignores the erection of a male patient during perineal care. C. The nurse documents the perineal care. D. The nurse only completes perineal care with daily bathing. E. The nurse can delegate perineal care. Answer: A, B, C, E Explanation: Gloves, professionalism, documentation, and delegation are standard practices for perineal care. Why Other Options Are Wrong: D is incorrect because perineal care may be needed more frequently, especially for incontinent patients. 6. The nurse should avoid soaking the feet of which patient population? (Select all that apply.) A. Patients with peripheral vascular disease. B. Patients with a stroke. C. Patients with diabetes. D. Patients with arthritis. E. Patients who are malnourished. Answer: A, B, C Explanation: Soaking increases infection and skin breakdown risks in patients with vascular or sensory deficits. Why Other Options Are Wrong: D and E have no contraindications for foot soaking. 7. The nurse notes that a trauma patient has multiple tangles in the hair. Which actions taken by the nurse are appropriate? (Select all that apply.) A. Work the tangles to the ends of the hair, then trim with scissors. B. Apply warm water and conditioner. C. Apply detangler as available. D. Use a comb or fingers to work through tangles. E. Cut the tangles out if working on them agitates the patient. Answer: B, C, D Explanation: Conditioner, detangler, and gentle combing safely address tangles without cutting hair. Why Other Options Are Wrong: A and E are inappropriate unless patient consent is obtained for cutting.