ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 32 : Hygiene Questions
Question 1 of 5
A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is 'itchy.' Which intervention is appropriate?
Correct Answer: B
Rationale: An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.
Question 2 of 5
A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply.
Correct Answer: B,C,D,F
Rationale: Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.
Question 3 of 5
When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply.
Correct Answer: A,C,F
Rationale: During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.
Question 4 of 5
A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
Correct Answer: A,E,F
Rationale: Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.
Question 5 of 5
A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next?
Correct Answer: D
Rationale: If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.