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

Wash hands for 10 seconds after caring for the client.

Monitor the client for manifestations of dehydration.

Use toilet paper to remove stool from the client's skin.

Administer diphenoxylate/atropine to the client.

Answer and Explanation

The Correct Answer is B

A) "Wash hands for 10 seconds after caring for the client.": Proper hand hygiene is critical in preventing the spread of infections, but the recommended duration for handwashing is at least 20 seconds. This option does not specify the necessary steps to ensure effective hand hygiene.

B) "Monitor the client for manifestations of dehydration.": Older adults are at a higher risk of dehydration due to gastroenteritis, which can cause significant fluid loss through vomiting and diarrhea. Monitoring for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and reduced urine output, is a priority in managing their condition and preventing complications.

C) "Use toilet paper to remove stool from the client's skin.": While keeping the client clean is important, using toilet paper might not be sufficient or gentle enough to effectively clean and protect the skin. Using appropriate cleansing methods and skin care products is better for maintaining skin integrity.

D) "Administer diphenoxylate/atropine to the client.": While this medication can help reduce diarrhea, it may not be the first action to take. In some cases, stopping diarrhea too quickly can prevent the elimination of harmful pathogens. Monitoring and addressing hydration status is more critical initially in the management of gastroenteritis.

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Correct Answer is D

Explanation

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

A. Fever B. Hypernatremia C. Hypertension D. Hypoglycemia

Correct Answer is B

Explanation

A) Fever: Myxedema coma is characterized by hypothermia rather than fever. The client with myxedema coma may experience a lowered body temperature, reflecting the severe hypothyroidism associated with this condition.

B) Hypernatremia: Hypernatremia, or elevated sodium levels, is a common finding in myxedema coma. This occurs due to impaired renal function and decreased aldosterone levels, leading to an imbalance in electrolytes, including sodium.

C) Hypertension: Typically, myxedema coma presents with hypotension rather than hypertension. The condition is associated with decreased cardiac output and low blood pressure, not elevated blood pressure.

D) Hypoglycemia: In myxedema coma, hypoglycemia is not typically expected. Instead, patients may experience hypoglycemia due to reduced metabolic rate and decreased glycogen stores. However, hyperglycemia is more commonly observed in other endocrine disorders, not specifically in myxedema coma.

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

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