Ch 5

Question 1

The nurse asks the nursing student to give a client early morning care before breakfast. What would the nursing student do for this client??

1. Provide for elimination needs, a bath or shower, and oral care
2. Provide for elimination needs, wash face and hands, and give a back massage
3. Provide care only as needed by this client
4. Provide a urinal or bedpan, wash the face and hands, and give oral care

Answer 1

4

Question 2

Which factors may influence a person’s personal hygiene practices? Select all that apply

1. Culture
2. Religion
3. Health and energy
4. Personal preference
5. Development level

Answer 2

1, 2, 3, 4, 5

Question 3

Medication is to be placed in the client’s bath water and the client is to remain in the tub for 20-30 minutes. Which type of bath will the nurse provide this client?

1. A partial bath
2. A therapeutic bath
3. A cleaning bath
4. A bag bath

Answer 3

2

Question 4

An unlicensed assistive personnel (UAP) is caring for an older client with dementia. Which action by the UAP would require intervention by the nurse?

1. Performing morning care as quickly as possible to minor client disruption
2. Using a supportive, calm approach and praising the client often
3. Stopping the bath when the client becomes distressed
4. Using a gentle touch with the client

Answer 4

1

Question 5

The nurse is teaching the UAP about using a safety razor to shave facial hair. Which action by the UAP indicates successful teaching by the nurse?

1. Shaved the client using no cream or water to reduce friction
2. Holds the razor blade at a 90* angle to the skin
3. Holds the skin taut to prevent cutting the skin
4. After shaving, rubs the face dry

Answer 5

3

Question 6

A home care nurse is instructing a client with diabetes and peripheral vascular disease about foot care. Which statement made by the client demonstrates understanding of the material?

1. “I will first dip my toes in the water to check the temperature”
2. “I will wash my feet every 2 days if I notice excessive sweating”
3. “I will cut my toenails to an appropriate length”
4. “When my feet are cold, I will use extra blankets and wear warm socks”

Answer 6

4

Question 7

Which if the following would be appropriate for the nurse to delegate to UAP?

1. Bathing a client diagnosed with hemophilia (bleeding disorder)
2. Bathing a client diagnosed with osteogenesis imperfecta (disorder with abnormal bone fragility)
3. Bathing an anxious client who is scheduled for surgery this morning
4. Bathing a client diagnosed with chronic atrial fibrillation (irregular heart beat)

Answer 7

4

Question 8

The nurse is preparing to bathe an 18 month old child and begins by waving which part of the child’s body first?

1. Abdomen
2. Diaper area
3. Face
4. Extremities

Answer 8

3

Question 9

The nurse is bathing an 85 year old woman recently admitted to the hospital with a fractured right humerus. While performing the bath the nurse notices several bruises on the woman’s back in various stages of healing, a 1 inch wide abrasion that starts at the shoulder and ends at the lumbar spine area, and a bump on the back of her head. What would be the nurse’s priority action?

1. Accurately document the assessment findings and call the PCP immediately to report them
2. Document the bruises and abrasion in the clients chart and mention the findings the next time the PCP arrives
3. Report the abuse of the client to the authorities immediately
4. Document the assessment findings in the clients medical record.

Answer 9

1

Question 10

While providing hygienic care to the client, the nurse notes a large amount of a yellow waxy substance in the clients ear canal. The nurse documents which of the following as cleaned from the clients ear canal?

1. Yellow waxy substance
2. Cerumen
3. Earwax
4. Purulent material

Answer 10

2