A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Allow the perineal area to air dry after each stool.

Administer a soap-suds enema to cleanse the colon.

Provide the client with a high fiber diet.

Apply a zinc-oxide barrier to the perineal area after each stool.

Answer and Explanation

The Correct Answer is D

A. Allow the perineal area to air dry after each stool. While drying is important, leaving the skin unprotected can lead to skin breakdown and irritation from continued exposure to stool.

B. Administer a soap-suds enema to cleanse the colon. Soap-suds enemas are contraindicated in diarrhea because they can cause further irritation and electrolyte imbalances.

C. Provide the client with a high-fiber diet. A high-fiber diet is recommended for constipation, not diarrhea, as fiber can increase stool frequency.

D. Apply a zinc-oxide barrier to the perineal area after each stool. Zinc-oxide protects the skin from moisture and irritation, helping prevent dermatitis and skin breakdown.

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Correct Answer is D

Explanation

A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.

B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.

C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.

D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.

A. Check the client's toes for color, temperature, and sensation. B. Apply heat to the client's ankle. C. Apply a compression bandage to the client's ankle. D. Encourage range of motion of the client's foot. E. Elevate the client's foot.

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

Explanation

A. Check the client's toes for color, temperature, and sensation: Assesses neurovascular status to detect signs of impaired circulation or nerve injury.

B. Apply heat to the client's ankle: Heat can increase swelling; ice should be used instead (RICE method: Rest, Ice, Compression, Elevation).

C. Apply a compression bandage to the client's ankle: Helps reduce swelling and provides support.

D. Encourage range of motion of the client's foot: Movement may worsen injury if a fracture or soft tissue damage is present.

E. Elevate the client's foot: Reduces swelling by promoting venous return.

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A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

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