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Skills in Clinical Nursing 8th Edition by Audrey J. – Test Bank 

 

Exam
Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) The recommended technique for the nurse to use when brushing the client’s teeth is the: 1) A) Sulcular technique. B) Xerostomia technique. C) Gingivitis technique. D) Pyorrhea technique. Answer: A Explanation: A) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation B) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation C) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation D) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-1: Define the key terms used in the skills of hygienic care. 1
2) The nurse is caring for a client who had abnormal hair growth as a side effect of medical treatment.
The nurse documents this as: 2) A) Alopecia. B) Hirsutism. C) Pediculosis. D) Scabies. Answer: B Explanation: A) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment B) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment C) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment D) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-1: Define the key terms used in the skills of hygienic care. 2
3) The nurse is planning the day, and will perform morning care: 3) A) When the client first awakens. B) After breakfast. C) Before retiring for the night. D) Whenever the client requests it. Answer: B Explanation: A) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning B) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning C) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning D) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning Objective: Learning Outcome 5-2: Describe the kinds of hygienic care nurses provide to clients. 4) The nurse must assess which of the following prior to providing personal hygienic care? Select all
that apply. 4) A) Allergies B) Culture C) Ability to provide self-care D) Social history E) Diagnosis Answer: A, B, C, E Explanation: A) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment 3
B) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment C) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment D) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment E) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-2: Describe the kinds of hygienic care nurses provide to clients. 5) The nurse recognizes that personal hygiene is impacted by which of the following? Select all that
apply. 5) A) Culture B) Environment C) Allergies D) Developmental level E) Health and energy Answer: A, B, D, E 4
Explanation: A) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment B) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment C) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment D) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment 5
E) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-3: Identify factors that influence personal hygiene. 6) When preparing the bag bath for the client, a priority nursing action is to: 6) A) Wet 10-12 disposable washcloths. B) Dry the client after using a washcloth. C) Use one washcloth for the lower extremities. D) Warm the washcloth in the microwave. Answer: D Explanation: A) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-4: Describe various types of baths. 6
7) The nurse is caring for a healthy 20-year-old client who was involved in a motor vehicle crash resulting in a fractured femur. The femur was pinned, and the client was placed in traction. What
type of bath would the nurse provide for this client? 7) A) Complete bed bath B) Self-help bed bath C) Partial bath D) Bag bath Answer: B Explanation: A) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-3: Identify factors that influence personal hygiene. 7
8) The nurse is bathing a client with dementia. Which of the following actions would require
corrective teaching? 8) A) The nurse who sings to the client while bathing B) The nurse who moves slowly from one area to another, explaining what he is going to do next C) The nurse who offers praise for the client’s cooperation D) The nurse who rubs areas dry after washing them Answer: D Explanation: A) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation B) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation C) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation D) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 9) The nurse is bathing a client with dementia who has been cooperating throughout the process. As
the nurse prepares to bath the client’s genitalia, the female client starts screaming, “No! Don’t touch
me there! Rape!” What would be the nurse’s best course of action? 9) A) Stop and assess the cause of the distress. B) Explain that the client needs to be cleaned, but it will be done in a second. C) Proceed with the bath but finish quickly. D) Finish the bath without touching the genitalia. Answer: A Explanation: A) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation8
B) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation C) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation D) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 10) The nurse delegates bathing a client to the unlicensed assistive personnel (UAP), and does which of
the following? Select all that apply. 10) A) Informs the UAP what type of bath is appropriate. B) Describes precautions specific to the needs of the client. C) Tells the UAP who to notify if she has any concerns. D) Informs the UAP to encourage the client to perform as much self-care as appropriate. E) Has the UAP document the bathing experience for the nurse to read later. Answer: A, B, D Explanation: A) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning 9
B) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning C) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning D) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning E) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 11) Which of the following clients would the nurse need to wear gloves to bathe? 11) A) The client diagnosed with HIV/AIDS B) The newborn just admitted from the delivery room C) The client with psoriasis D) The postoperative client Answer: B 10
Explanation: A) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation B) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation C) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation D) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 11
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 12) Place the following steps in the proper order when providing perineal-genital care for a female:
1 . Apply gloves. 2 . Wipe from the pubis to the rectum. 3 . Place a towel under the client’s hips. 4 . Clean the labia minora. 5 . Position and drape the client. 6 . Clean the labia majora. 12) Answer: 3, 5, 1, 6, 4, 2 Explanation: The nurse first places a towel under the client’s hip to protect the bed. The
female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to
minimize exposure. Apply gloves and clean the labia majora, then open the
labia to clean the labia minora using separate quarters of the washcloth for each
stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order
to avoid bringing bacteria from the rectum toward the urethra, which could
result in a urinary tract infection.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 13) The best device to stimulate blood circulation in the scalp when the nurse provides hair care is: 13) A) A stiff-bristle brush. B) A soft-bristle brush. C) A sharp-bristle brush. D) A comb with dull, even teeth. Answer: A Explanation: A) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation B) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation12
C) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation D) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 13
14) While providing foot care to the diabetic client, the nurse notes very dry skin. Which of the
following would be the nurse’s best action? 14) A) Apply a pleasantly scented lotion to the foot, using care to rub the lotion in between the toes. B) Assist the client to soak his feet in warm water twice a day. C) Instruct the client to avoid the use of lotions and creams. D) Instruct the client to use a non-scented lotion, avoiding the area between the toes. Answer: D Explanation: A) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation B) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation C) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation D) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 14
15) Which of the following would the nurse document after providing hair care to the client? 15) A) Number of times the hair was combed or brushed throughout the shift B) Type of brush used to provide hair care C) Abnormal assessments D) Routine nursing interventions Answer: C Explanation: A) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-8: Demonstrate appropriate documentation and reporting of hygienic care. 15
16) Routine hygienic care has been provided to the client, with no abnormal findings assessed. Which
of the following would the nurse document? 16) A) Foot care B) Hair care C) Removal or insertion of a hearing aid D) Type of bath provided and client’s ability to provide self-care Answer: D Explanation: A) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-8: Demonstrate appropriate documentation and reporting of hygienic care. 16

 

Exam
Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) The recommended technique for the nurse to use when brushing the client’s teeth is the: 1) A) Sulcular technique. B) Xerostomia technique. C) Gingivitis technique. D) Pyorrhea technique. Answer: A Explanation: A) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation B) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation C) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation D) The sulcular technique aims the toothbrush at an angle toward the gums, and is
recommended as the best means of brushing the client’s teeth. Xerostomia is the
term for dry mouth, and there is no technique associated with it. Gingivitis is a
form of periodontal disease causing red swollen gingiva. Pyorrhea is loose teeth
and pus that is evident when the gums are pressed.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-1: Define the key terms used in the skills of hygienic care. 1
2) The nurse is caring for a client who had abnormal hair growth as a side effect of medical treatment.
The nurse documents this as: 2) A) Alopecia. B) Hirsutism. C) Pediculosis. D) Scabies. Answer: B Explanation: A) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment B) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment C) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment D) Hirsutism is abnormal hair growth. Alopecia is hair loss. Pediculosis is commonly
known as lice. Scabies is a contagious skin infection caused by mites.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-1: Define the key terms used in the skills of hygienic care. 2
3) The nurse is planning the day, and will perform morning care: 3) A) When the client first awakens. B) After breakfast. C) Before retiring for the night. D) Whenever the client requests it. Answer: B Explanation: A) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning B) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning C) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning D) The nurse generally provides morning care after breakfast. Early-morning care is provided when the client first awakens. Hour of sleep (HS) care is provided before
going to bed. PRN care is provided as required by the client.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning Objective: Learning Outcome 5-2: Describe the kinds of hygienic care nurses provide to clients. 4) The nurse must assess which of the following prior to providing personal hygienic care? Select all
that apply. 4) A) Allergies B) Culture C) Ability to provide self-care D) Social history E) Diagnosis Answer: A, B, C, E Explanation: A) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment 3
B) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment C) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment D) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment E) The nurse needs to assess for allergies to avoid a reaction to the products used
during hygienic care. The client’s culture will impact how he meets his daily
hygiene needs. The client should be encouraged to perform as much of his hygiene
care as possible, so the nurse must assess his ability to provide self-care. The client’s diagnosis will impact how much care he can tolerate at one time and his
ability to move about in bed.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-2: Describe the kinds of hygienic care nurses provide to clients. 5) The nurse recognizes that personal hygiene is impacted by which of the following? Select all that
apply. 5) A) Culture B) Environment C) Allergies D) Developmental level E) Health and energy Answer: A, B, D, E 4
Explanation: A) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment B) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment C) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment D) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment 5
E) The client’s hygiene is influenced by culture. While North Americans place great
value on cleanliness, not all cultures share this value. The client’s environment, and
access to finances, can have an impact on how often she bathes and what products
she uses. Developmental levels will determine what the client can or is willing to
do for herself. People who don’t feel well, or have low energy levels, might not
attend to hygiene in the way they did when they felt well. While allergies can
impact what product she chooses to use in order to maintain her hygiene needs, it
will not impact the client’s hygiene needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment Objective: Learning Outcome 5-3: Identify factors that influence personal hygiene. 6) When preparing the bag bath for the client, a priority nursing action is to: 6) A) Wet 10-12 disposable washcloths. B) Dry the client after using a washcloth. C) Use one washcloth for the lower extremities. D) Warm the washcloth in the microwave. Answer: D Explanation: A) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) The package arrives with 10-12 presoaked disposable washcloths that the nurse must warm in the microwave. Once the washcloths are safely warmed, the nurse
uses one washcloth on each area of the body (one for each arm, one for each leg),
Drying is not necessary because the solution on the washcloths are no-rinse cleanser that will dry quickly.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-4: Describe various types of baths. 6
7) The nurse is caring for a healthy 20-year-old client who was involved in a motor vehicle crash resulting in a fractured femur. The femur was pinned, and the client was placed in traction. What
type of bath would the nurse provide for this client? 7) A) Complete bed bath B) Self-help bed bath C) Partial bath D) Bag bath Answer: B Explanation: A) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) This client is self-sufficient, and only needs some assistance reaching areas such as the back and the feet. A complete bath is when the nurse bathes all areas of the
body, which would not be necessary with a healthy young adult. A bag bath is a
bath using no-rinse solution, which would not be necessary for this client because there is available water and bathing products. A partial bath would be incomplete
for this client, who is bedridden for several weeks and will require a full bath.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-3: Identify factors that influence personal hygiene. 7
8) The nurse is bathing a client with dementia. Which of the following actions would require
corrective teaching? 8) A) The nurse who sings to the client while bathing B) The nurse who moves slowly from one area to another, explaining what he is going to do next C) The nurse who offers praise for the client’s cooperation D) The nurse who rubs areas dry after washing them Answer: D Explanation: A) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation B) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation C) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation D) When bathing a client with dementia, the nurse should pat areas dry, using a soft
touch, rather than rubbing. The remaining actions follow proper technique.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 9) The nurse is bathing a client with dementia who has been cooperating throughout the process. As
the nurse prepares to bath the client’s genitalia, the female client starts screaming, “No! Don’t touch
me there! Rape!” What would be the nurse’s best course of action? 9) A) Stop and assess the cause of the distress. B) Explain that the client needs to be cleaned, but it will be done in a second. C) Proceed with the bath but finish quickly. D) Finish the bath without touching the genitalia. Answer: A Explanation: A) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation8
B) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation C) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation D) The nurse’s best course of action is to stop and assess for the cause of the distress.
The nurse can adjust the approach to reduce the client’s anxiety. It would not be
healthy to avoid washing the genitals, especially if the client has experienced
incontinence or leakage, but even without these concerns, the genitalia must be
cleaned regularly to avoid tissue damage. Proceeding with the bath while the
client screams is not ideal; a better strategy would be to encourage the client to
wash her own genitalia with some guidance or assistance.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 10) The nurse delegates bathing a client to the unlicensed assistive personnel (UAP), and does which of
the following? Select all that apply. 10) A) Informs the UAP what type of bath is appropriate. B) Describes precautions specific to the needs of the client. C) Tells the UAP who to notify if she has any concerns. D) Informs the UAP to encourage the client to perform as much self-care as appropriate. E) Has the UAP document the bathing experience for the nurse to read later. Answer: A, B, D Explanation: A) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning 9
B) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning C) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning D) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning E) The nurse would inform the UAP what type of bath and what precautions are
appropriate for that specific client’s needs. While it is often faster to perform the
entire bath without encouraging client participation, the UAP should take her time
and encourage the client to perform as much self-care as possible to promote the client’s autonomy. The nurse does not need to tell the UAP to whom to report
concerns, because they should be reported to the nurse. The nurse should instruct
the UAP to report about the bathing experience as soon as it is completed, and the
nurse would not wait to read the UAP’s documentation.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning Objective: Learning Outcome 5-5: Describe guidelines for bathing persons with dementia. 11) Which of the following clients would the nurse need to wear gloves to bathe? 11) A) The client diagnosed with HIV/AIDS B) The newborn just admitted from the delivery room C) The client with psoriasis D) The postoperative client Answer: B 10
Explanation: A) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation B) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation C) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation D) The nurse should wear gloves when bathing the newborn just admitted from the
delivery room because of the high likelihood of blood and body fluids found on the
baby. The client with HIV/AIDS or psoriasis, or the postoperative client, would not
require the nurse to wear gloves unless there was bleeding or drainage from open
wounds.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 11
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 12) Place the following steps in the proper order when providing perineal-genital care for a female:
1 . Apply gloves. 2 . Wipe from the pubis to the rectum. 3 . Place a towel under the client’s hips. 4 . Clean the labia minora. 5 . Position and drape the client. 6 . Clean the labia majora. 12) Answer: 3, 5, 1, 6, 4, 2 Explanation: The nurse first places a towel under the client’s hip to protect the bed. The
female client should be positioned in a back-lying position with the knees flexed and spread well apart. Cover the body and legs with the bath blanket to
minimize exposure. Apply gloves and clean the labia majora, then open the
labia to clean the labia minora using separate quarters of the washcloth for each
stroke. After cleaning the genitalia, wipe from the pubis to the rectum in order
to avoid bringing bacteria from the rectum toward the urethra, which could
result in a urinary tract infection.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 13) The best device to stimulate blood circulation in the scalp when the nurse provides hair care is: 13) A) A stiff-bristle brush. B) A soft-bristle brush. C) A sharp-bristle brush. D) A comb with dull, even teeth. Answer: A Explanation: A) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation B) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation12
C) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation D) A stiff-bristle brush that is not so sharp as to injure the client’s scalp is best to stimulate blood circulation in the scalp. A soft-bristle brush would not stimulate the scalp or effectively prevent mats. A sharp-bristle brush could scratch the scalp. A comb would not stimulate the scalp.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 13
14) While providing foot care to the diabetic client, the nurse notes very dry skin. Which of the
following would be the nurse’s best action? 14) A) Apply a pleasantly scented lotion to the foot, using care to rub the lotion in between the toes. B) Assist the client to soak his feet in warm water twice a day. C) Instruct the client to avoid the use of lotions and creams. D) Instruct the client to use a non-scented lotion, avoiding the area between the toes. Answer: D Explanation: A) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation B) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation C) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation D) Clients with diabetes often have extremely dry skin, and should be taught to use a
non-perfumed lotion and avoid putting lotion between the toes. They should be advised not to soak their feet in water, because it is drying to the skin.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation Objective: Learning Outcome 5-7: Verbalize the steps used when: A. Bathing an adult or pediatric client. B. Providing perineal-genital care. C . Brushing and flossing the teeth. D. Providing special oral care. E. Providing hair care. F . Providing foot care. G . Removing, cleaning, and inserting a hearing aid. 14
15) Which of the following would the nurse document after providing hair care to the client? 15) A) Number of times the hair was combed or brushed throughout the shift B) Type of brush used to provide hair care C) Abnormal assessments D) Routine nursing interventions Answer: C Explanation: A) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) Generally, daily combing and brushing of the hair are not recorded, but the nurse
should document any abnormal or unusual findings during assessment.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-8: Demonstrate appropriate documentation and reporting of hygienic care. 15
16) Routine hygienic care has been provided to the client, with no abnormal findings assessed. Which
of the following would the nurse document? 16) A) Foot care B) Hair care C) Removal or insertion of a hearing aid D) Type of bath provided and client’s ability to provide self-care Answer: D Explanation: A) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation B) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation C) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation D) The nurse would document what type of bath was provided to the client and the
client’s ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected
assessment findings.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation Objective: Learning Outcome 5-8: Demonstrate appropriate documentation and reporting of hygienic care. 16