The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Fluid volume deficit.

Caregiver role strain.

Bowel incontinence.

Impaired bed mobility.

Answer and Explanation

The Correct Answer is A

A.   Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B.   While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C.   This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D.   Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The client presents with facial droop and garbled speech, which are classic symptoms of a stroke. The CT scan ruled out intracranial hemorrhage, aligning with ischemic stroke symptoms. The neurological assessment indicated left-sided facial droop, diminished hand grasp strength, and garbled speech, all of which are consistent with neurological deficits typically seen in a stroke.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

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The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

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