The nurse identifies a client problem of impaired skin integrity related to diarrhea for a client who has ulcerative colitis. The nurse recognizes that teaching about perianal care has been effective when the client:
cleans and dries the perianal area after each diarrheal stool.
uses alcohol compresses to provide relief from anal irritation.
asks for antidiarrheal medication after each stool.
takes an hour-long Sitz bath following each stool.
The Correct Answer is A
A. Cleans and dries the perianal area after each diarrheal stool: This is the correct option. Effective perianal care for a client with diarrhea, such as ulcerative colitis, involves gentle cleansing and thorough drying of the perianal area after each stool. Proper hygiene helps prevent skin breakdown and irritation caused by prolonged contact with stool.
B. Alcohol can be irritating to the skin and may exacerbate perianal irritation and discomfort. Therefore, using alcohol compresses is not considered an appropriate perianal care practice.
C. While antidiarrheal medications may be prescribed for clients with ulcerative colitis to help manage symptoms, asking for medication after each stool is not a typical or recommended approach. The frequency and timing of antidiarrheal medication administration should be based on healthcare provider recommendations and individual symptom management plans.
D. While Sitz baths can provide relief from perianal discomfort and promote healing, taking an hour-long Sitz bath after each stool may be impractical and excessive. Sitz baths are typically recommended for shorter durations (e.g., 10-20 minutes) and may be used periodically rather than after every stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Abdominal pain and cramping are common symptoms of diverticular disease, particularly diverticulosis and diverticulitis. The pain is often located in the lower left abdomen and can range from mild to severe. Cramping may occur due to inflammation or spasms in the affected colon segment.
A. Frequent urination is not a common symptom of diverticular disease. Diverticular disease typically involves symptoms related to the gastrointestinal tract, such as abdominal pain, changes in bowel habits, and rectal bleeding.
C. Symptoms related to the chest are more commonly associated with cardiovascular or respiratory conditions rather than gastrointestinal conditions like diverticular disease.
D. Joint stiffness is more commonly associated with musculoskeletal conditions such as arthritis or other inflammatory disorders.
Correct Answer is C
Explanation
C. Thirst, polyuria, and abdominal pain are symptoms commonly associated with hyperglycemia. High blood glucose levels can lead to osmotic diuresis, causing increased urination and thirst. Abdominal pain may occur due to gastrointestinal symptoms related to hyperglycemia, such as bloating or discomfort.
A. Blurred vision, weakness, tingling of extremities are more indicative of hypoglycemia rather than hyperglycemia.
B. Hunger, shakiness, confusion are symptoms of hypoglycemia rather than hyperglycemia.
D. While tachycardia and anxiety can occur with various medical conditions, oliguria is not typically associated with hyperglycemia.
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