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 ["A","B","C"]
Explanation
A. Proper use of prescribed oxygen in the home: This is a crucial aspect of care for a client with emphysema. Oxygen therapy may be prescribed to help manage symptoms and improve oxygenation. Proper use of prescribed oxygen equipment at home, including understanding flow rates, wearing oxygen as prescribed, and ensuring adequate oxygen saturation, is essential for the client's safety and well-being.
B. Smoking cessation is paramount for individuals diagnosed with emphysema. Smoking is the primary cause of emphysema, and continuing to smoke can exacerbate symptoms, accelerate disease progression, and decrease the effectiveness of treatment.
C. Regular exercise is beneficial for individuals with emphysema as it can help improve cardiovascular health, strengthen respiratory muscles, enhance endurance, and improve overall quality of life. However, exercise should be tailored to the individual's abilities and limitations.
D. High carbohydrate, low protein diet is not appropriate for individuals with emphysema. In fact, a high carbohydrate, low protein diet may contribute to weight gain and exacerbate respiratory symptoms.
E. While individuals with emphysema may need to take precautions to avoid exposure to respiratory infections, such as practicing good hand hygiene and avoiding close contact with individuals who are sick, there is no need to avoid playing with grandchildren altogether.
Correct Answer is D
Explanation
D. In paralytic ileus, there is a lack of bowel motility, resulting in absent or diminished bowel sounds on auscultation and absent passage of flatus. The bowel sounds may be hypoactive or completely absent due to the lack of peristalsis. Additionally, the client may experience abdominal distention and discomfort due to the accumulation of gas and fluid in the intestines.
A. Pencil-thin stools are more commonly associated with conditions such as colorectal cancer or rectal strictures. In paralytic ileus, where there is a lack of bowel motility, the stools are typically absent rather than thin.
B. Fecal-smelling breath is not a typical finding in paralytic ileus. While it may occur in conditions associated with severe constipation or bowel obstruction, it is not specific to paralytic ileus.
C. Passage of mucus and blood in stools is not a characteristic finding of paralytic ileus. It is more commonly associated with conditions such as inflammatory bowel disease or colorectal cancer.
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