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. Request a prescription for an indwelling urinary catheter. Long-term catheter use increases the risk of infection and is not the first-line intervention for functional incontinence.

B. Remind the client to tell the nurse when he has to urinate. Clients with dementia often have difficulty recognizing or communicating the need to urinate.

C. Take the client to the bathroom on an every-2-hr schedule. Scheduled toileting helps manage incontinence by anticipating the client’s needs and reducing accidents.

D. Use adult diapers to prevent frequent clothing changes. This does not address the underlying issue and may contribute to skin breakdown and decreased dignity.

A. A reddened area over the sacrum B. Difficulty moving the upper extremities C. Stiffness in the lower extremities D. Difficulty hearing some types of sounds

Correct Answer is A

Explanation

A. A reddened area over the sacrum. This is an early sign of a pressure ulcer, a common complication of immobility in bed-bound clients.

B. Difficulty moving the upper extremities. While weakness may occur after a stroke, this is not a complication of immobility but rather a direct effect of neurological damage.

C. Stiffness in the lower extremities. Some stiffness may occur, but contractures or deep vein thrombosis (DVT) would be more concerning immobility-related complications.

D. Difficulty hearing some types of sounds. Hearing loss is not a complication of immobility.

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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

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Correct Answer is C

Explanation

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Correct Answer is A

Explanation

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