A nurse in a provider's office is caring for a client.

Exhibit 1

Medical History

Initial visit:

Client reports a sedentary lifestyle.

Client is lactose intolerant and denies taking vitamin supplements.

Client is a nonsmoker.

Client does not drink alcohol.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

A. Grab bars are installed in the shower: Installing grab bars in the shower is a safety measure that helps prevent falls and assists the client in safely maneuvering in the bathroom. This finding indicates a safe environment and does not require intervention.

B. The hot water heater is set to 47°C (117°F): The hot water heater set at 47°C (117°F) poses a scalding risk, especially for older adults with decreased sensation or mobility issues. The recommended safe temperature for hot water heaters is typically below 49°C (120°F) to prevent burns. Therefore, the nurse should intervene to adjust the temperature to a safer level.

C. There is an area rug covering a tile floor.

Area rugs covering tile floors can pose a significant fall risk, especially for older adults with osteoporosis, who are more susceptible to fractures. The rug can slip or bunch up, leading to trips and falls. Therefore, the nurse should intervene to remove the area rug or secure it firmly to the floor to prevent accidents.

D. Prescriptions are stored in a medication organizer: Storing prescriptions in a medication organizer promotes medication adherence and organization, which is beneficial for older adults managing multiple medications. This finding indicates good medication management and does not require intervention.

A. Apply the pouch while the skin barrier is still damp.

Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

B. Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

C. Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma:a allows for a better fit and helps prevent the edges of the stoma from coming into contact with stool, which can cause irritation and breakdown of the skin. A proper fit also helps ensure a secure seal and prevents leakage.