Chapter 27 Hygiene and Personal Care

Chapter 27  Hygiene and Personal Care

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse knows that which of the following statements is true regarding the importance of hygiene?
a.
The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath.
b.
UAPs perform hygiene because there is no benefit of nurses doing it.
c.
The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene.
d.
The main purpose of bathing is to decrease odor.

ANS: A
The bath is an excellent opportunity for the nurse to assess multiple body systems. Although the UAP can perform hygiene, there is benefit to the nurse doing it because of the ability to assess the patient. The mucous membranes are a part of the integumentary system, and bathing cleanses the skin, provides comfort, and contributes to the patient’s health and well-being.

DIF: Applying REF: p. 518 OBJ: 27.01 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Caregiving

2. Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable nursing diagnosis for a patient with excessively dry skin?
a.
Imbalanced Nutrition: Less than body requirements
b.
Deficient fluid volume
c.
Risk for infection
d.
Acute pain

ANS: C
Any interruption in the skin, which is the body’s first line of defense, can potentially lead to infection. Both imbalanced nutrition and deficient fluid volume could have dry skin as a symptom. Acute pain is not appropriate.

DIF: Evaluating REF: p. 519 OBJ: 27.02 TOP: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Caregiving

3. The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?
a.
Patient with asthma
b.
Patient with attention deficit hyperactivity disorder
c.
Patient with a stroke
d.
Patient with diabetes

ANS: D
Patients with neurologic deficits such as peripheral neuropathy resulting from diabetes may not be able to identify extremes of hot and cold. Patients with attention deficit hyperactivity disorder and asthma are not likely to be injured by temperature extremes. Patients with a stroke may have some alteration in sensation on one side of their body but can compensate by using the other side, and they are at less risk than a patient with diabetes.

DIF: Analyzing REF: p. 519 OBJ: 27.02 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Caregiving

4. Which tool is used to determine risk for impaired skin integrity?
a.
Braden scale
b.
Glasgow scale
c.
Vanderbilt scale
d.
MMSE scale

ANS: A
The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.

DIF: Understanding REF: p. 521 OBJ: 27.03
TOP: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: Concepts: Caregiving

5. The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:
a.
ineffective health maintenance.
b.
readiness for enhanced self-care.
c.
hygiene self-care deficit.
d.
disturbed body image.

ANS: B
Readiness for enhanced self-care is evidenced by a patient expressing a desire to be independent in ADLs. Ineffective health maintenance is an inability to maintain health, hygiene self-care deficit indicates they are unable to perform hygiene, and disturbed body image relates to how they view their body.

DIF: Evaluating REF: p. 521 OBJ: 27.04 TOP: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Caregiving