A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Cleanse the perineal area from back to front.

Wash the perineal area with povidone-iodine twice daily

Change the perineal pad with each void

"Wipe the perineal area with a soft cloth."

Answer and Explanation

The Correct Answer is C

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

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Correct Answer is D

Explanation

d. Corn tortillas with black beans.

Explanation:

Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.

Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.

A. Use written signs to assist the client with locating the bathroom. B. Limit the number of choices for the client. C. Provide a stimulating environment for the client. D. Use confrontation to manage the client's behavior.

Correct Answer is ["B"]

Explanation

Answer: B

Rationale:

A) Use written signs to assist the client with locating the bathroom: While written signs may be helpful in the earlier stages of Alzheimer's disease, as the disease progresses, clients may lose the ability to read and comprehend written language. Visual cues, such as pictures or color-coded indicators, tend to be more effective in helping clients navigate their environment.

B) Limit the number of choices for the client: Limiting choices reduces confusion and anxiety for clients with Alzheimer's disease. Providing too many options can overwhelm them, making decision-making difficult. Offering simple, clear choices helps to maintain a sense of autonomy while minimizing stress.

C) Provide a stimulating environment for the client: Although some stimulation can be beneficial, excessive stimulation can overwhelm a client with Alzheimer's disease, leading to agitation and confusion. It's important to create a calm, structured environment that promotes safety and reduces anxiety.

D) Use confrontation to manage the client’s behavior: Confrontation should be avoided when managing the behavior of clients with Alzheimer's disease. Confronting or challenging them can increase agitation and lead to further confusion. Instead, caregivers should use distraction, redirection, and a calm approach to manage difficult behaviors effectively.

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A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is ["B"]

Explanation

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