Chapter 27: Hygiene and Personal Care Yoost & Crawford: Fundamentals of Nursing

1. The nurse knows that which statement is true regarding the importance of hygiene? a. The nurse can assess other body systems during the bath. b. UAPs perform hygiene because there is no benefit of nurses doing this care. 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 the patient’s body odor. 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. Impaired Health Maintenance b. Risk for Injury c. Risk for infection d. Acute pain 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 4. Which tool is used by the nurse to determine risk for impaired skin integrity? a. Braden scale b. Glasgow scale c. Vanderbilt scale d. MMSE scale 5. The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one? a. Patient will ambulate independently twice a day. b. Patient will perform all own ADLs. c. Patient will consume 75% of all meals. d. Patient will begin to perform 25% of own ADLs. 6. The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first? a. Hands b. Eyes c. Face d. Arms