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) "Drink whole milk instead of skim milk": Whole milk contains higher levels of saturated fats compared to skim milk. For individuals with hyperlipidemia, it is advisable to reduce intake of saturated fats to help lower cholesterol levels and improve heart health. Drinking skim or low-fat milk is a healthier option to manage lipid levels.

B) "Limit saturated fat to 15 percent of total daily fat intake": The American Heart Association recommends that saturated fat intake should be limited to less than 7% of total daily calories for those managing hyperlipidemia. Limiting saturated fat to 15% is too high and can contribute to increased cholesterol levels, negatively impacting cardiovascular health.

C) "Select trans fats for daily fat intake": Trans fats are known to significantly raise LDL (bad) cholesterol levels and lower HDL (good) cholesterol, increasing the risk of heart disease. It is essential to avoid trans fats altogether in the diet, as they are detrimental to cardiovascular health.

D) "Replace red meat with fish three times per week": Replacing red meat with fish, especially fatty fish like salmon, mackerel, and sardines, can be beneficial for individuals with hyperlipidemia. Fish is a good source of omega-3 fatty acids, which can help lower triglyceride levels, reduce inflammation, and improve overall heart health. This dietary change supports better lipid management and reduces the risk of cardiovascular diseases.

A. Orthostatic hypotension B. Clubbing of the nail beds C. Conjunctivitis D. Heat intolerance

Correct Answer is A

Explanation

A) Orthostatic hypotension: Anemia often results in decreased blood volume and oxygen-carrying capacity, which can cause orthostatic hypotension. This condition is characterized by a sudden drop in blood pressure when moving from a sitting or lying position to standing, leading to dizziness or fainting.

B) Clubbing of the nail beds: Clubbing is typically associated with chronic hypoxia and long-term respiratory or cardiovascular diseases, rather than anemia. It involves the enlargement of the fingertips and changes in the angle of the nail bed.

C) Conjunctivitis: Conjunctivitis is an inflammation of the conjunctiva, usually caused by infections, allergies, or irritants. It is not a common manifestation of anemia.

D) Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism or other metabolic disorders rather than anemia. Individuals with anemia are more likely to experience cold intolerance due to reduced oxygen delivery to tissues.

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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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