A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Turn the client every 4 hr.

Cleanse the perineal area with povidone-iodine solution.

Apply cornstarch powder to the perineal area.

Place a moisture barrier ointment over the perineal area.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.

Choice B Reason:

Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.

Choice C Reason:

Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.

Choice D Reason:

Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.

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Correct Answer is B

Explanation

Choice A Reason:

"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.

Choice B Reason:

"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.

Choice C Reason:

"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.

Choice D Reason:

"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.

A. Ask the client to state their room number. B. Have the client state their phone number. C. Request an assistive personnel to identify the client. D. Review the client's photograph in the medical record.

Correct Answer is D

Explanation

Choice A Reason:

Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.

Choice B Reason:

Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.

Choice C Reason:

Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.

Choice D Reason:

Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.

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A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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