A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Allow the perineal area to air dry after each stool.

Administer a soap-suds enema to cleanse the colon.

Provide the client with a high fiber diet.

Apply a zinc-oxide barrier to the perineal area after each stool.

Answer and Explanation

The Correct Answer is D

A. Allow the perineal area to air dry after each stool. While drying is important, leaving the skin unprotected can lead to skin breakdown and irritation from continued exposure to stool.

B. Administer a soap-suds enema to cleanse the colon. Soap-suds enemas are contraindicated in diarrhea because they can cause further irritation and electrolyte imbalances.

C. Provide the client with a high-fiber diet. A high-fiber diet is recommended for constipation, not diarrhea, as fiber can increase stool frequency.

D. Apply a zinc-oxide barrier to the perineal area after each stool. Zinc-oxide protects the skin from moisture and irritation, helping prevent dermatitis and skin breakdown.

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Correct Answer is C

Explanation

A. Assess fluid balance. While assessment is important, treatment of dehydration (rehydration) is the priority in severe diarrhea.

B. Introduce a regular diet. Introducing a regular diet should come after rehydration, as severe diarrhea can lead to fluid and electrolyte imbalance that must be corrected first.

C. Rehydrate. The immediate priority is fluid replacement (oral or IV) to prevent hypovolemia, electrolyte imbalances, and shock.

D. Maintain fluid therapy. Maintaining fluid therapy is important after rehydration has begun, but initial rehydration is the priority intervention.

A. "I isolate myself in my room for a few hours when things get overwhelming." B. "I think about being on my favorite beach vacation." C. "I call a friend who makes me smile and laugh." D. "I tense and release my muscles, starting with my feet." E. "I sleep in in the mornings."

Correct Answer is ["B","C","D"]

Explanation

A. "I isolate myself in my room for a few hours when things get overwhelming." Social isolation can contribute to emotional distress rather than alleviate stress effectively.

B. "I think about being on my favorite beach vacation." This is an example of visualization or guided imagery, a healthy coping mechanism to reduce stress.

C. "I call a friend who makes me smile and laugh." Social support is a well-known strategy for managing stress in a positive manner.

D. "I tense and release my muscles, starting with my feet." This describes progressive muscle relaxation, a recognized technique to relieve stress and anxiety.

E. "I sleep in in the mornings." While rest is important, excessive sleeping may indicate avoidance rather than healthy stress management.

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A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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