Chapter 19: Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition

1. The nurse instructs the patient that any injury to the skin initially puts the patient at risk for: a. scar formation at the injury site resulting from the healing process. b. infection with bacteria or viruses that may affect the person systemically. c. loss of sensation caused by damage to the nerves in the area. d. loss of body fluids and an upset in the fluid and electrolyte balance. 2. When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to: a. call his primary care provider about the amount of exertion in physical therapy. b. suggest the patient walks slowly in the hall to “cool down.” c. offer additional fluids to replace those lost through normal cooling. d. place a light cover over the patient to prevent his chilling. 3. During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the: a. patient will shower daily on an independent basis by the end of 1 month. b. nurse will give a tub bath or full bed bath daily. c. patient will shower or tub bathe with assistance twice a week. d. patient will tub bathe or shower with assistance daily. 4. In assessing the skin condition of an older adult patient, the nurse notes that, over the sacral area, there is a 2 cm × 3 cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be: a. “Patient has stage II ulcer on sacrum. No blanching of perimeter.” b. “Reddened area over sacrum, skin open in center.” c. “Pressure ulcer on sacrum. Massaged with no improvement in color.” d. “2 cm × 3 cm reddened area on sacrum with open center. Does not blanch.” 5. When instructing a nursing assistant about hygiene needs of a frail older adult patient, the nurse correctly educates the nursing assistant to: a. “Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling.” b. “Put bath oil in the tub and use plenty of soap to really clean the patient’s skin while she is in the tub.” c. “Use brisk drying and an alcohol rub to close the patient’s pores and prevent heat loss after the bath.” d. “Completely dry the patient’s skin and apply a mild moisturizer.” 6. An important factor to consider when assessing the hygiene needs of a patient is that: a. the patient knows best what is needed in his hygiene routine. b. the routine of the agency will determine when the patient is able to bathe. c. hygiene is not as important as other needs of the patient. d. the patient may not have the same hygiene practices as the nurse. 7. What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak? a. Perform a full bed bath, brush and floss his teeth, and give him a good back massage. b. Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary. c. Set up a washbasin and supplies, tell the patient to wash what he can, and provide privacy for the patient to do what he can. d. Teach a family member to give a full bath so that the family member will be able to care for the patient at home. 8. The patient most at risk for a pressure ulcer would be: a. a 46-year-old man in traction for a fractured femur, who exercised regularly before his accident and is alert and oriented. b. a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed. c. a 72-year-old man admitted for elective surgery to replace his hip joint, who was an avid bowler and gardener before his hip disease slowed him down. d. an 84-year-old man with Alzheimer disease who is pacing in the halls and who is incontinent of urine if not toileted every 2 hours.