The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?
Fluid volume deficit.
Bowel incontinence.
Caregiver role strain.
Impaired bed mobility.
The Correct Answer is A
Choice A Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.
Choice B Reason: This is incorrect because bowel incontinence is a significant problem that can affect the client's dignity, comfort, and skin integrity, but it is not as urgent as fluid volume deficit. The nurse should implement a bowel management program and provide appropriate hygiene and skin care.
Choice C Reason: This is incorrect because caregiver role strain is a potential problem that can affect the parent's well-being and ability to provide care, but it is not as critical as fluid volume deficit. The nurse should assess the parent's coping skills, support system, and respite needs.
Choice D Reason: This is incorrect because impaired bed mobility is a chronic problem that can affect the client's functional status and quality of life, but it is not as serious as fluid volume deficit. The nurse should assist the client with positioning, turning, transferring, and exercising.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because explaining that alternative treatment options may be helpful can be insensitive and unrealistic, as it may raise false hopes or imply that the husband's condition is not serious.
Choice B Reason: This is correct because encouraging the wife to share her feelings can help her cope with her grief and express her emotions in a supportive environment. The nurse should use active listening and empathic responses.
Choice C Reason: This is incorrect because offering reassurance that she is not alone can be dismissive and invalidating, as it may minimize her feelings or imply that she should not feel lonely.
Choice D Reason: This is incorrect because reminding her that her husband may still live a long time can be dishonest and inappropriate, as it may contradict the medical prognosis or imply that she should not prepare for his death.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.
Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.
Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.
Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today