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 ["A","C","E"]

Explanation

A) Headache:
Headache is a common adverse effect of albuterol due to its action on the central nervous system. The medication can cause vasodilation and changes in blood flow, leading to headaches. Parents should be aware of this potential side effect and manage it accordingly.

B) Hypotension:
Hypotension is not a typical adverse effect of albuterol. Albuterol primarily acts as a beta-2 agonist, leading to bronchodilation and some cardiovascular effects, but it generally does not cause a drop in blood pressure. Instead, it may occasionally increase blood pressure in some individuals.

C) Hyperactivity:
Hyperactivity is a known side effect of albuterol, especially in children. This occurs due to the stimulant effects of the medication on the central nervous system, leading to increased restlessness and activity levels. Parents should monitor their child's behavior for signs of increased hyperactivity.

D) Decreased pulse rate:
Decreased pulse rate (bradycardia) is not associated with albuterol use. Albuterol tends to cause tachycardia, an increased heart rate, due to its beta-adrenergic stimulating effects. Monitoring the pulse rate is essential, but a decreased rate is not a typical concern with this medication.

E) Tremors:
Tremors are a common adverse effect of albuterol, resulting from the stimulation of beta-adrenergic receptors in the muscles. This can cause muscle shaking or jitteriness, particularly in the hands. Parents should be informed about this possible side effect and observe their child for signs of tremors.

A. Sensorineural deafness B. Maculopapular rash C. Swelling of the parotid glands D. Nuchal rigidity

Correct Answer is C

Explanation

A) Sensorineural deafness
This is a possible complication of mumps but not a symptom indicating the illness stage. It can occur after the infection and does not reflect the active phase of the disease.

B) Maculopapular rash
This type of rash is not typically associated with mumps. It may indicate other viral infections, such as measles or rubella, rather than mumps.

C) Swelling of the parotid glands
Swelling of the parotid glands is a hallmark symptom of the illness stage of mumps. This swelling typically appears a few days after the onset of other symptoms like fever and malaise and signifies the active phase of the infection.

D) Nuchal rigidity
Nuchal rigidity can occur if there is mumps-related meningitis, but it is not a typical sign of the initial illness stage. It indicates potential complications involving the central nervous system.

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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?

Nursing Test Bank

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

Explanation

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Explanation

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