A client who is mentally impaired is incontinent of stool. What is the nurse's best intervention to help prevent skin breakdown?

Place a pad under the buttocks

Check the rectal area for soiling frequently

Wash the buttocks with strong soap and water

Place the call bell in the client's reach

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.

Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.

Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.

Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct interpretation. An occlusion of the right coronary artery is a blockage of the blood flow to the right side of the heart, which can cause a heart attack or ischemia. This condition does not produce a systolic murmur, but rather chest pain, shortness of breath, sweating, or nausea. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice B reason: This is not a correct interpretation. An aneurysm of the descending aorta is a bulging or weakening of the wall of the large artery that carries blood from the heart to the lower body. This condition does not produce a systolic murmur, but rather a pulsating mass in the abdomen, back pain, or abdominal pain. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice C reason: This is not a correct interpretation. Decreased fluid in the pericardial sac is a condition where the amount of fluid that surrounds and cushions the heart is reduced. This can be caused by dehydration, infection, or inflammation. This condition does not produce a systolic murmur, but rather a pericardial friction rub, which is a scratching or grating sound that occurs when the layers of the pericardium rub against each other. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice D reason: This is the correct interpretation. Distortion of one or more heart valves is a condition where the shape or function of the valves that regulate the blood flow through the heart is altered. This can be caused by congenital defects, rheumatic fever, endocarditis, or aging. This condition can produce a systolic murmur, which is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve. The location and the intensity of the murmur can help identify which valve is affected. A systolic murmur in the second intercostal space to the right of the sternum can indicate a problem with the aortic valve.

A. Have analgesic properties without sedation B. Can trigger vasodilation and improve blood flow C. Improve contractility and decrease afterload D. Inhibit platelet aggregation and clot formation

Correct Answer is A

Explanation

Choice A reason: Having analgesic properties without sedation is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that prevent blood clots from forming in the arteries that supply the heart. They do not have significant analgesic or sedative effects.

Choice B reason: Triggering vasodilation and improving blood flow is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not directly cause vasodilation or increase blood flow. They work by reducing the stickiness of platelets and preventing them from clumping together and blocking the arteries.

Choice C reason: Improving contractility and decreasing afterload is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not affect the contractility or the afterload of the heart. They act on the blood vessels and the blood cells, not on the heart muscle. Contractility and afterload are influenced by other drugs such as beta-blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors.

Choice D reason: This is the correct answer. Inhibiting platelet aggregation and clot formation is the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that interfere with the function of platelets, which are blood cells that help with clotting. By inhibiting platelet aggregation and clot formation, aspirin and clopidogrel reduce the risk of heart attack and stroke in people with coronary artery disease.

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A client who is mentally impaired is incontinent of stool. What is the nurse's best intervention to help prevent skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

Correct Answer is D

Explanation

The nurse recognizes that the rationale for the medical prescription of aspirin 81 mg PO daily and clopidogrel 75 mg PO daily for the client with coronary artery disease is that these medications:

Correct Answer is A

Explanation

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