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

Explanation

A) "I can add lean turkey to a salad.": Lean turkey is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based sources. Including iron-rich foods like lean turkey in the diet helps address iron-deficiency anemia effectively.

B) "I should choose apples over strawberries.": Apples are not particularly high in iron compared to strawberries. While apples provide some nutrients, strawberries contain more vitamin C, which enhances iron absorption from other foods.

C) "I can take an iron supplement with milk to enhance the effect.": Milk and other dairy products can inhibit iron absorption due to their calcium content. It is recommended to take iron supplements with vitamin C-rich beverages like orange juice to enhance absorption.

D) "I should consume coffee or tea with my meals.": Coffee and tea contain compounds like polyphenols that can inhibit iron absorption when consumed with meals. It's better to avoid these beverages around meal times to improve iron absorption.

A. Decreased systolic blood pressure B. Decreased anteroposterior chest diameter C. Increased cerumen thickness D. Increased saliva production

Correct Answer is C

Explanation

A) Decreased systolic blood pressure: In older adults, systolic blood pressure often increases due to stiffening of the arteries rather than decreasing. This increase in systolic blood pressure is due to reduced elasticity in blood vessels, making it a common physiological change.

B) Decreased anteroposterior chest diameter: In fact, the anteroposterior chest diameter often increases with age due to changes in the rib cage and spine, such as kyphosis. An increased chest diameter is observed in older adults, not a decrease.

C) Increased cerumen thickness: As people age, cerumen (earwax) production can increase and the cerumen can become thicker and drier. This is due to changes in the ceruminous glands and can lead to more frequent earwax impaction in older adults, making it a relevant point to include in the educational program.

D) Increased saliva production: Typically, older adults experience a decrease in saliva production, not an increase. Reduced saliva production can contribute to difficulties with chewing, swallowing, and oral health.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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