A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
Turn the client every 4 hr.
Cleanse the perineal area with povidone-iodine solution.
Apply cornstarch powder to the perineal area.
Place a moisture barrier ointment over the perineal area.
The Correct Answer is D
Choice A Reason:
Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.
Choice B Reason:
Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.
Choice C Reason:
Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.
Choice D Reason:
Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Correct Answer is D
Explanation
Choice A Reason:
Chicken is incorrect. Chicken is a type of poultry and is a meat product. Lacto-vegetarians do not consume meat, including poultry, as part of their dietary choices.
Choice B Reason:
Clam chowder is incorrect. Clam chowder is a soup typically made with clams and often contains ingredients like broth or cream, which may not align with a lacto-vegetarian diet. It includes seafood, which is excluded in lacto-vegetarian dietary practices.
Choice C Reason:
Tuna fish is incorrect. Tuna fish is a type of seafood and is not consumed in lacto-vegetarian diets. Lacto-vegetarians exclude all types of fish and seafood from their diet and primarily consume dairy products along with plant-based foods.
Given that the client follows a lacto-vegetarian diet, the most appropriate food choice from the options provided would be:
Choice D is Reason:
Cheese is correct. A lacto-vegetarian diet includes dairy products but excludes meat and seafood. Cheese, being a dairy product, aligns with the lacto-vegetarian dietary pattern as it is derived from milk and fits within the dietary preferences of this individual.
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