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 ["A","D"]
Explanation
A. A family history of esophageal cancer is a known risk factor. Genetic factors can increase the likelihood of developing esophageal cancer, especially if close family members have had the condition.
B. A diet high in glucose is not specifically associated with an increased risk of esophageal cancer. However, poor dietary habits in general, such as a high intake of processed foods or low fiber, can contribute to other health issues.
C. Irregular exercise is not a major risk factor for esophageal cancer. However, a lack of physical activity can contribute to overall health problems, including obesity, which is a known risk factor for some cancers.
D. Smoking tobacco is a significant risk factor for esophageal cancer. Smoking can damage the esophagus and increase the risk of developing both squamous cell carcinoma and adenocarcinoma of the esophagus.
Correct Answer is A
Explanation
A. Reviewing electrolyte values is the first action to take, as clients with acute exacerbations of ulcerative colitis are at risk for electrolyte imbalances due to diarrhea and fluid loss. It is essential to correct any imbalances promptly to avoid complications like cardiac arrhythmias.
B. While obtaining a dietary history is important to understand the client's eating habits and trigger foods, it is not the priority when the client is experiencing an acute exacerbation. Addressing immediate physiological needs comes first.
C. Checking perianal skin integrity is important, as diarrhea and frequent bowel movements can lead to irritation or breakdown of the skin, but this is not the first priority in the acute phase of exacerbation. Managing electrolyte levels and hydration takes precedence.
D. Investigating emotional concerns is important in the holistic care of the patient, but it is not the first priority in managing an acute exacerbation of ulcerative colitis. Ensuring the client is physically stable through electrolyte management is more urgent.
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