A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which of the following responses should the nurse identify as the speech alteration of echolalia?

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to

the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.

The other options are not correct.

b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.

c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.

d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.