Upgrade to remove ads
Only $2.99/month

NURS 112: NCLEX questions - Taylor Ch 31

Terms in this set (35)

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

a) Older adults
b) Adolescents
c) Middle-aged adults
d) School-aged children
b) Adolescents

As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a person ages, bathing frequently decreases, and older people may not use deodorant due to excessive drying of the skin.
Which patient is most likely to require hospitalization related to problems associated with the feet?

a) A patient with diabetes insipidus
b) A patient with osteoporosis
c) A patient with asthma
d) A patient with peripheral vascular disease
d) A patient with peripheral vascular disease

Foot problems, particularly common in people with diabetes mellitus and peripheral vascular disease, often require hospitalization.
A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

a) Stomatitis
b) Gingivitis
c) Glossitis
d) Periodontitis
c) Glossitis

Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa.
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of which of the following?

a) Alopecia
b) Pediculosis
c) Ticks
d) Flease
b) Pediculosis

Infestation with lice is called pediculosis and results in frequent scratching and marks on the scalp. Alopecia is the absence or loss of hair. Ticks and fleas can cause itching, but pediculosis is best described by this scenario.
The nurse assists the patient to the bathroom sink to perform morning care. The nurse observes the patient wash his face, arms, abdomen, and legs. The nurse washes the patient's back and rectal area and applies soap to the back. The patient brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the patient's chart?

a) Self-care
b) Complete care
c) Partial care
d) As-needed care
c) Partial care

Morning care is categorized as self-care, partial care, or complete care. Patients identified as partial care most often 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. Patients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. Patients identified as complete care require nursing assistance with all aspects of personal hygiene. In additional to scheduled care, the nurse will offer care as needed.
Which of the following does the nurse recognize as the most important component of the oral care process is when providing oral care?

a) Selection of toothpaste
b) A thorough mechanical cleaning
c) Use of a mouthwash or breath freshener
d) Application of moisturizing ointment to the lips
b) A thorough mechanical cleaning

Following the steps for cleaning the mouth thoroughly is more important than the agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning of the oral cavity.
During morning care, the nurse notices a glass-like appearance to the patient's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretions related to illness?

a) Normal saline solution
b) Hydrogen peroxide solution
c) Boric acid solution
d) Soap and water
a) Normal saline solution

Wear gloves and use water or normal saline and cotton balls or a clean washcloth or compress to clean the eyes. Boric acid, once popular for cleaning the eyes, is no longer recommended, and the nurse should never use hydrogen peroxide or soap and water to clean the eyes.
Upon review of the patient's orders, the nurse notes that the patient was recently started on an anticoagulant. What is an appropriate consideration when assisting the patient with morning hygiene?

a) Avoid massaging the patient's back with lotion.
b) Do not allow the patient to shower.
c) Provide the patient with an electric shaver.
d) Provide the patient with a firm bristled toothbrush.
c) Provide the patient with an electric shaver.

Electric shavers are recommended when a patient is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the patient is more prone to bleeding and the firm bristles may lead to bleeding. The patient should be allowed to shower, unless there are other contraindications, and a back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.
The nurse and nursing aid are providing perineal care for an incontinent patient. What information is important for the nurse to consider when providing perineal care?

a) Aggressively cleanse the perineal area with a washcloth or towel.
b) Wash the perineal area frequently with soap and water.
c) Apply moisture barriers to the skin of the perineal area.
d) Provide excessive hydration to the skin of the perineal area.
c) Apply moisture barriers to the skin of the perineal area.

Care to the perineal area for an incontinent patient includes the use of moisture barriers, skin cleansers, and moisturizers and the avoidance of the use of soap or friction. Measures should be followed to reduce over-hydration because this will increase the risk for perineal damage and skin breakdown.
Positioning the patient's bed for safety is an important nursing measure. Which of the following must the nurse assure before leaving the patient's room?

a) The bed controls are in a locked position.
b) The side rails are in the lowered position.
c) The bed is in its highest position.
d) The wheels or casters are locked.
d) The wheels or casters are locked.

To promote bed safety, the nurse will assure that the wheels or casters are locked, the side rails are raised, the bed controls are functioning, and the bed is in its lowest position.
The nurse has completed an assessment of a patient's typical hygiene practices. How should the nurse best document the findings of this assessment in the patient's chart?

a) "Patient's level of personal hygiene is acceptable and age-appropriate."
b) "Patient prioritizes personal hygiene in her daily routines and is proactive with skin care."
c) "Patient normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms."
d) "Patient bathes more often than necessary and consequently experiences dry skin."
c) "Patient normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms."

When documenting the nursing history, it is best to be specific, clearly describing the patient's typical hygiene practices and any complaints. Judgments regarding cause and effect are likely premature in this context and may be inaccurate.
Which of the following health problems is most clearly suggestive of a history of inadequate dental care?

a) Cheilosis
b) Periodontitis
c) Dry oral mucosa
d) Alopecia
b) Periodontitis

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. Cheilosis is indicative of vitamin deficiency while dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss.
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which of the following teaching points should the nurse prioritize when educating the parents of students who have lice and nits?

a) The need to destroy all clothing and bedding that the child has used
b) The fact that the health problem is self-limiting
c) The importance of teaching their children adequate personal hygiene habits
d) The importance of completely finishing the prescribed treatment.
d) The importance of completely finishing the prescribed treatment.

When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the patient will shampoo the hair once and not follow through with a second washing. Pediculosis requires treatment and is not self-limiting. It is not necessarily a reflection of inadequate hygiene and is not necessary to destroy the child's clothing and bedding.
An elderly resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?

a) Use a non-soap cleaning agent.
b) Use organic soap and shampoo.
c) Bathe the patient more often, but without using soap or shampoo.
d) Provide the patient with bed baths rather than tub baths.
a) Use a non-soap cleaning agent.

Soap cleans the skin, but at the same time 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. The substitution of a non-soap emollient cleaning agent is an easy way to prevent drying and damage to the skin. An organic soap is not necessarily less drying to the skin and it would be inappropriate to forego the use of any cleaning products whatsoever. Providing a bed bath rather than a tub bath will not necessarily minimize dry skin.
An elderly patient has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the patient's dentures?

a) Arrange for a minced or pureed diet for the patient so that dentures are not necessary.
b) Send the dentures home with a friend or family member until the patient is discharged.
c) Store the patient's dentures in water when the patient is not wearing them.
d) Encourage the patient to wear her dentures 24 hours a day to prevent their loss.
c) Store the patient's dentures in water when the patient is not wearing them.

Dentures should be stored in water when they are not being worn by the patient. It would be inappropriate to eliminate the use of the dentures while the patient is being treated, as this may compromise the patient's nutrition and the future fit of the dentures. It is normally not advisable for patients to wear their dentures 24 hours per day.
For which of the following patients is foot care likely the highest priority?

a) A patient who is obese and has a diagnosis of type 1 diabetes
b) A patient who has experienced postoperative pneumonia and has been placed on a ventilator
c) A patient who has been diagnosed with Alzheimer disease and whose mobility is decreasing
d) A patient who has chronic renal failure and requires hemodialysis three times weekly
a) A patient who is obese and has a diagnosis of type 1 diabetes

Patients with diabetes mellitus have an increased need for vigilant foot care, due to the risk of skin breakdown and foot wounds that often accompany the disease.
A nurse is providing perineal care for a female patient who has a decreased level of consciousness. Which of the following techniques should the nurse employ when providing this care?

a) Wipe from the pubic area toward the anal area.
b) Avoid the use of soap and cleansers when providing perineal care.
c) Begin cleaning at more contaminated areas and mover to cleaner areas.
d) Apply a small amount of talcum powder to the patient's perineum after cleansing.
a) Wipe from the pubic area toward the anal area.

When providing perineal care for a female patient, the nurse should move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over the genital area. Always proceed from the least contaminated area to the most contaminated area. Soap should be used, but talcum should be avoided because it may promote bacterial growth.
A nurse is preparing to provide foot care to a patient who has decreased mobility. Which of the following techniques should the nurse employ when providing this care?

a) Carefully remove any corns or calluses that are present.
b) Avoid using soaps or commercial cleansers whenever possible.
c) Use an antifungal powder on the patient's feet if necessary.
d) Soak the patient's feet for 15 to 20 minutes prior to cleansing.
c) Use an antifungal powder on the patient's feet if necessary.

Antifungal foot powders may be used when indicated, and it is appropriate to use soap and/or cleansers when providing foot care. Corns and calluses should not be removed and the nurse should avoid soaking the patient's feet.
When performing health education regarding hygiene, the nurse should advise female patients to avoid the use of which of the following? Select all that apply.

a) Routine douching
b) Vaginal deodorants
c) Tampons
d) Commercial soap
e) Scented sanitary napkins
a) Routine douching
b) Vaginal deodorants

Douching has also been linked to vaginal irritation, bacterial vaginosis, pelvic inflammatory disease, and sexually transmitted infections (STIs), while deodorants to control odor around the vaginal orifice are unnecessary. The use of tampons, soap, and scented sanitary napkins is not inadvisable unless the patient has a specific contraindication.
A patient has been recently admitted to the hospital unit following a suspected stroke and a family member states that the patient's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the patient's lenses after removal?

a) Hypotonic solution
b) Sterile water
c) Hypertonic solution
d) Normal saline
d) Normal saline

Contact lenses are most commonly stored in normal saline.
When planning for completion of a patient's personal hygiene, it is most important to consider which of the following?

a) When the patient has his or her most recent bath
b) The patient's usual hygiene practices and preferences
c) Where the bathing fits in the nurse's schedule
d) The time that is convenient for the patient care assistant
b) The patient's usual hygiene practices and preferences

Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important but the patient's preferences are a higher priority.
Why is adequate oral hygiene an essential part of nursing care? Select all that apply.

a) It promotes the patient's sense of well-being.
b) It prevents deterioration of the oral cavity.
c) It contributes to decreased incidence of aspiration pneumonia.
d) It eliminates the need for flossing.
e) It decreases oropharyngeal secretions.
a) It promotes the patient's sense of well-being.
b) It prevents deterioration of the oral cavity.
c) It contributes to decreased incidence of aspiration pneumonia.

Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing (d) or decrease oropharyngeal secretions (e).
During a bath, the nurse observes that a patient has dry skin. Which action would be best?

a) Bathe the patient more frequently.
b) Use an emollient on the dry skin.
c) Massage the skin with alcohol.
d) Discourage fluid intake.
b) Use an emollient on the dry skin.

An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin.
Which recommendation by the nurse to an adolescent patient with acne would be most appropriate?

a) Wash the skin twice a day.
b) Use cosmetics liberally to cover blackheads.
c) Use emollients on the area.
d) Squeeze blackheads as they appear.
a) Wash the skin twice a day.

Washing the skin removes oil and debris, whereas liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discourage because it may lead to infection.
The nurse observes a marked inflammation of the gums, and recession and bleeding of the gums and documents this observation using which term?

a) Glossitis
b) Caries
c) Cheilosis
d) Periodontitis
d) Periodontitis

Periodontitis is a marked inflammation of the gums, whereas caries refers to the presence of tooth decay. Cheilosis is ulceration of the lips, and glossitis is an inflammation of the tongue.
Which action would be the priority when administering oral care to a dependent patient?

a) Assisting the patient to the dorsal recumbent position
b) Wearing disposable gloves
c) Using a firm toothbrush to cleanse teeth and gums
d) Irrigating forcefully with hydrogen peroxide
b) Wearing disposable gloves

Disposable gloves provide a barrier to protect the nurse and patient. The dorsal recumbent position is unsafe because the patient may easily aspirate any secretions or fluids. A soft toothbrush is recommended to avoid causing irritation and bleeding, and forceful irrigation is never safe. Water would be the choice for any gentle irrigation.
Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes?

a) Using hydrogen peroxide
b) Wiping from the outer canthus to the inner canthus
c) Positioning him on the same side as the eye to be cleansed
d) Using only one cotton ball per eye
c) Positioning him on the same side as the eye to be cleansed

Positioning the patient on the same side as involved eye discourages contamination of the other eye. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. Water or normal saline should be used for cleansing the ey of any discharge, and one cotton ball should be used for each stroke.
Which of the following interventions would the nurse include in the plan of care when providing foot care to an older patient?

a) Using scissors to correct an ingrown toenail
b) Trimming toenails as short as possible
c) Using an alcohol rub if the feet are dry
d) Bathing the feet at least daily
d) Bathing the feet at least daily

An older patient should have foot care once daily. Correcting an ingrown toenail should be done by a podiatrist, and trimming the toenails may require a physician's order. Cutting the toenails as short as possible exposes tender area to friction and may lead to the skin being cut during trimming. Alcohol is drying and should not be used when dry skin is usually already a problem.
Providing perineal care to a patient requires which of the following?

a) Using a clean portion of the washcloth for each stroke
b) Moving from most contaminated to least contaminated area
c) Using sterile gloves
d) Leaving the foreskin undisturbed in an uncircumcised adult male
a) Using a clean portion of the washcloth for each stroke

A clean portion of the washcloth should be used for each stroke to prevent contamination of other areas. Cleansing should always proceed from the least contaminated to the most contaminated area. Clean gloves, not sterile gloves, are used to provide perineal care. The foreskin in an uncircumcised male should be pulled back to allow cleansing underneath and then gently returned to its former position.
A nurse is caring for an 80-year-old patient who has become weak and fatigues easily. He is unable to wash his body and always asks the nurse to brush his teeth. Based on this information, which of the following is an appropriate nursing diagnosis for this patient?

a) Risk for Impaired Skin Integrity relate to immobility
b) Bathing/Hygiene Self-Care Deficit related to decreased strength and endurance
c) Social Isolation related to lack of visitors
d) Impaired Oral Mucous Membrane related to inability to brush his teeth
b) Bathing/Hygiene Self-Care Deficit related to decreased strength and endurance

Risk for Impaired Skin Integrity, Social Isolation, Impaired Oral Mucous Membrane may be appropriate nursing diagnoses for this patient. However, not enough is known, based on the information given, to formulate these diagnoses. The priority at this time, based on the given information, is Bathing/Hygiene Self-Care Deficit.
An older patient with an unsteady gait requests a tub bath. Which of the following actions would be most appropriate?

a) Add Alpha-Keri oil to the water to prevent dry skin.
b) Allow the patient to lock the door to guarantee privacy.
c) Assist the patient in and out of the tub to prevent falling.
d) Keep the water temperature very warm because the patient chills easily.
c) Assist the patient in and out of the tub to prevent falling.

Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha-Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43 degrees to 46 degrees C. Older patients have an increased susceptibility to burns due to diminished sensitivity.
During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, what should the nurse do?

a) Have him sign a permission form.
b) Check to see if the patient is taking anticoagulants.
c) Tell him that only a family member may shave a patient.
d) Position him flat in bed.
b) Check to see if the patient is taking anticoagulants.

A patient who is taking anticoagulants should be shaved with an electric razor rather than a blade razor. Shaving a patient does not require a permission form be signed and can be completed by either the caregiver or a family member. A shave is best completed with the patient in a Fowler's or semi-Fowler's position to prevent soap and water from running behind the patient's head.
An unresponsive patient is wearing gas-permeable contact lenses. How would the nurse remove these lenses?

a) Gently irrigate the eye with an irrigating solution from the inner canthus outward.
b) Grasp the lens with a gently pinching motion.
c) Don sterile gloves before attempting the removal procedure.
d) Ensure that the lens is centered on the cornea before gently manipulating the lids to release it.
d) Ensure that the lens is centered on the cornea before gently manipulating the lids to release it.

The lens must be situated on the cornea, not the sclera, before removal. To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean, not sterile, gloves are used.
The nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do?

a) Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve.
b) Cut the gown with scissors to allow arm movement.
c) Thread the bag and tubing through the gown sleeve, keeping the line intact.
d) Temporarily disconnect the tubing from the IV container, threading it through the gown.
c) Thread the bag and tubing through the gown sleeve, keeping the line intact.

Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.
When making an occupied bed, which of the following is most important for the nurse to do?

a) Keep the bed in the low position
b) Use a bath blanket or top sheet for warmth and privacy
c) Constantly keep the side rails raised on both sides
d) Move back and forth from one side to the other when adjusting the linens
b) Use a bath blanket or top sheet for warmth and privacy

Using the bath blanket or top sheet keeps the patient warm and provides privacy. Keeping the bed in the low position and working over raised side rails may strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time consuming and disorganized.
THIS SET IS OFTEN IN FOLDERS WITH...