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 B

Explanation

A. The client takes a 20-min nap each afternoon. Taking a short nap is a healthy coping mechanism and does not indicate ineffective coping.

B. The client has gained 4.5 kg (10 lb) in the past month. Sudden weight gain can indicate emotional eating or stress-related metabolic changes, which are signs of ineffective coping.

C. The client takes a walk for 1 hr each day. Walking is a positive coping strategy that helps manage stress.

D. The client is taking a poetry class. Engaging in creative activities is a healthy coping mechanism that can reduce stress.

A. 4+ B. 3+ C. 2+ D. 1+

Correct Answer is B

Explanation

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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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

A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?

Correct Answer is B

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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Correct Answer is B

Explanation

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