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 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.
Question 2 of 5
A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response?
Correct Answer: A,B,C,F
Rationale: The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.
Question 3 of 5
A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes?
Correct Answer: D
Rationale: The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean.
Question 4 of 5
A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply.
Correct Answer: B,D,F
Rationale: The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.
Question 5 of 5
A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
Correct Answer: C
Rationale: The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the 'task of bathing' to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths.
Towel baths, washing under clothes, and bathing 'body sections' one day at a time, as well as dry shampoo or 'shower cap' shampoos, are additional options.