1. A nurse is preparing to provide hygiene care. Which principle should the nurse consider when
planning hygiene care?
a.Hygiene care is always routine and expected.
b.No two individuals perform hygiene in the same manner.
c. It is important to standardize a patient's hygienic practices.
d. During hygiene care do not take the time to learn about patient needs. - CORRECT
ANSWER-ANS: B
No two individuals perform hygiene in the same manner; it is important to individualize the
patient's care based on knowing about the patient's unique hygiene practices and preferences.
Hygiene care is never routine; this care requires intimate contact with the patient and
communication skills to promote the therapeutic relationship. In addition, during hygiene, the
nurse should take time to learn about the patient's health promotion practices and needs,
emotional needs, and health care education needs.
2. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family
customs. For which age group is the nurse most likely providing care?
a. Adolescent
b. Preschooler
c. Older adult
d.Adult - CORRECT ANSWER-ANS: B
Family customs play a major role during childhood in determining hygiene practices such as the
frequency of bathing, the time of day bathing is performed, and even whether certain hygiene
practices such as brushing of the teeth or flossing are performed. As children enter
adolescence, peer groups and media often influence hygiene practices. During the adult years
involvement with friends and work groups shape the expectations that people have about
personal appearance. Some older adults' hygiene practices change because of changes in
living conditions and available resources.
3. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is
in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the
patient takes a bath once a week and a sponge bath every other day. To provide ultimate care
for this patient, which principle should the nurse keep in mind?
a.
Patients who appear unkempt place little importance on hygiene practices.
b.
,Personal preferences determine hygiene practices and are unchangeable.
c.
The patient's illness may require teaching of new hygiene practices.
d.
All cultures value cleanliness with the same degree of importance. - CORRECT ANSWER-ANS:
C
The nurse must assist the patient in developing new hygiene practices when indicated by an
illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot
hygiene. Patients who appear unkempt often need further assessment regarding their ability to
participate in daily hygiene. Patients with certain types of physical limitations or disabilities often
lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining
cleanliness does not hold the same importance for some ethnic groups as it does for others.
4. The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the
patient says "I always bathe in the evening." Which action by the nurse is best?
a.
Defer the bath until evening and pass on the information to the next shift.
b.
Tell the patient that daily morning baths are the "normal" routine.
c.
Explain the importance of maintaining morning hygiene practices.
d.
Cancel hygiene for the day and attempt again in the morning. - CORRECT ANSWER-ANS: A
Allow the patient to follow normal hygiene practices; change the bath to evening. Patients have
individual preferences about when to perform hygiene and grooming care. Knowing the patient's
personal preferences promotes individualized care for the patient. Hygiene care is never routine.
Maintaining individual personal preferences is important unless new hygiene practices are
indicated by an illness or condition. Cancelling hygiene and trying again is not an option since
the nurse already knows the reason for refusal. Adapting practices to meet individual needs is
required.
5. A nurse is completing an assessment of the patient. Which principle is a priority?
a.
Foot care will always be important.
b.
, Daily bathing will always be important.
c.
Hygiene needs will always be important.
d.
Critical thinking will always be important. - CORRECT ANSWER-ANS: D
A patient's condition is always changing, requiring ongoing critical thinking and changing of
nursing diagnoses. Apply the elements of critical thinking as you use the nursing process to
meet patients' hygiene needs. Critical thinking will help you determine when foot care, daily
bathing, and hygiene needs are important and when they are not.
6. When providing hygiene for an older adult patient, the nurse closely assesses the skin. What
is the rationale for the nurse's action?
a. Outer skin layer becomes more resilient.
b. Less frequent bathing may be required.
c. Skin becomes less subject to bruising.
d. Sweat glands become more active. - CORRECT ANSWER-ANS: B
In older adults, daily bathing as well as bathing with water that is too hot or soap that is harsh
causes the skin to become excessively dry. As the patient ages, the skin thins and loses its
resiliency and moisture, and lubricating skin glands become less active, making the skin fragile
and prone to bruising and breaking.
7. The nurse is bathing a patient and notices movement in the patient's hair. Which action will
the nurse take?
a.
Use gloves to inspect the hair.
b.
Apply a lindane based shampoo immediately.
c.
Shave the hair off of the patient's head.
d.
Ignore the movement and continue. - CORRECT ANSWER-ANS: A
In community health and home care settings, it is particularly important to inspect the hair for lice
so appropriate hygienic treatment can be provided. If pediculosis capitis (head lice) is
suspected, the nurse must protect self against self infestations by handwashing and by using