A nurse is teaching a female client about personal hygiene. Which of the following client actions indicates an understanding of teaching?

The client brushes her teeth twice daily.

The client wipes back to front when toileting.

The client washes her perineum first when bathing.

The client takes a hot bubble bath every day.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.

B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.

C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.

D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.

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Correct Answer is C

Explanation

A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.

B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.

C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.

D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.

A. Skin cool to touch B. Jugular vein distention C. Headache D. Weak peripheral pulses

Correct Answer is C

Explanation

Rationale:

A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.

B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.

C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.

D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.

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A nurse is teaching a female client about personal hygiene. Which of the following client actions indicates an understanding of teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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