A nurse is caring for an older adult client who has gastroenteritis. Which of the following actions should the nurse take?

Wash hands for 10 seconds after caring for the client.

Monitor the client for manifestations of dehydration.

Use toilet paper to remove stool from the client's skin.

Administer diphenoxylate/atropine to the client.

Answer and Explanation

The Correct Answer is B

A) "Wash hands for 10 seconds after caring for the client.": Proper hand hygiene is critical in preventing the spread of infections, but the recommended duration for handwashing is at least 20 seconds. This option does not specify the necessary steps to ensure effective hand hygiene.

B) "Monitor the client for manifestations of dehydration.": Older adults are at a higher risk of dehydration due to gastroenteritis, which can cause significant fluid loss through vomiting and diarrhea. Monitoring for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and reduced urine output, is a priority in managing their condition and preventing complications.

C) "Use toilet paper to remove stool from the client's skin.": While keeping the client clean is important, using toilet paper might not be sufficient or gentle enough to effectively clean and protect the skin. Using appropriate cleansing methods and skin care products is better for maintaining skin integrity.

D) "Administer diphenoxylate/atropine to the client.": While this medication can help reduce diarrhea, it may not be the first action to take. In some cases, stopping diarrhea too quickly can prevent the elimination of harmful pathogens. Monitoring and addressing hydration status is more critical initially in the management of gastroenteritis.

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Correct Answer is D

Explanation

A) Restrict fluids to decrease lower extremity swelling: Restricting fluids is generally not recommended for managing peripheral arterial disease (PAD). Fluid restriction may not address the underlying vascular issues causing swelling and might lead to dehydration. The focus should be on improving circulation and managing PAD symptoms.

B) Limit exercise to 10 min twice a day: Exercise is a critical component of managing PAD, and limiting it to only 10 minutes twice a day may not provide sufficient benefit. Patients with PAD are often encouraged to engage in regular, supervised exercise programs to improve circulation and reduce symptoms.

C) Use ice packs to decrease leg pain: Using ice packs is not advisable for PAD. Cold can constrict blood vessels and potentially worsen symptoms. Warmth or gentle heat may be more beneficial for improving circulation and relieving pain.

D) Sit with legs dependent when having pain: Sitting with the legs dependent (hanging down) can help alleviate pain associated with PAD. This position helps increase blood flow to the lower extremities and can reduce pain caused by intermittent claudication, a common symptom of PAD.

A. Administer a sedative medication to the client. B. Encourage strenuous physical activity to decrease tension. C. Encourage the client to explore feelings that contribute to anxiety. D. Speak to the client using short and simple statements in calm voice.

Correct Answer is D

Explanation

A) Administer a sedative medication to the client: While sedative medications can help manage acute anxiety, they should not be the first intervention. Medication administration comes after attempting non-pharmacological strategies to de-escalate the situation.

B) Encourage strenuous physical activity to decrease tension: Strenuous physical activity can sometimes exacerbate anxiety rather than alleviate it, particularly during a panic-level episode. It might not be safe or effective for immediate calming.

C) Encourage the client to explore feelings that contribute to anxiety: Exploring feelings is more appropriate once the client has been calmed. During a panic-level anxiety episode, the client may not be able to engage in reflective thinking or communication effectively.

D) Speak to the client using short and simple statements in calm voice: Using short, simple statements in a calm voice helps to provide clear and concise communication, which can be grounding and reassuring for someone experiencing panic-level anxiety. This approach helps to de-escalate the situation by reducing confusion and agitation.

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A nurse is caring for an older adult client who has gastroenteritis. Which of the following actions should the nurse take?

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