A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?
Administer a soap-suds enema to cleanse the colon.
Soak in a sitz bath for 20 min after each stool.
Wipe perianal area with warm water and apply a barrier cream.
Cleanse with antimicrobial scrub and vigorously dry.
The Correct Answer is C
A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Strictureplasty is a surgical procedure, not a non-surgical procedure. It is used to treat strictures by widening them, typically in the gastrointestinal tract.
B. Strictureplasty does not remove strictures but rather works to widen or repair the narrowed areas, allowing for improved passage through the affected part of the gastrointestinal tract.
C. Strictureplasty is not used to repair fractures in bones. It is specifically used in the gastrointestinal system to treat strictures.
D. Strictureplasty is commonly performed in the treatment of Crohn's disease, particularly in cases where the disease causes strictures in the intestines. It is a procedure that can help maintain the integrity of the intestine by widening narrowed areas without the need for resection.
Correct Answer is C
Explanation
A. Night sweats are more commonly associated with conditions like tuberculosis or certain cancers, rather than pneumonia, although they could occasionally be seen in severe pneumonia.
B. Narrowed pulse pressure is not a typical sign of pneumonia and is more indicative of conditions such as shock or heart failure.
C. Confusion is a classic and often overlooked symptom of pneumonia in older adults. Pneumonia in this population can present with altered mental status or confusion rather than typical respiratory symptoms like cough and fever.
D. Bradycardia is not a typical finding in pneumonia. In fact, tachycardia (an increased heart rate) is more commonly seen as the body tries to compensate for the infection.
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