A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility.
Which of the following interventions should the nurse include in the plan?
Encourage fluid intake of at least 2 L/day.
Provide a low-fiber diet.
Administer a stimulant laxative daily.
Discourage physical activity.
The Correct Answer is A
Encourage fluid intake of at least 2 L/day.
This is because adequate hydration can help soften the stool and facilitate its passage through the intestines. Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.
Choice B is wrong because a low-fiber diet can contribute to constipation by reducing the bulk and water content of the stool.
Fiber helps retain water in the stool and stimulate peristalsis. A high-fiber diet is recommended for clients who have constipation.
Choice C is wrong because a stimulant laxative should not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa. Stimulant laxatives should be used only as a last resort when other measures fail.
Choice D is wrong because physical activity can help prevent constipation by increasing intestinal motility and blood flow. Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.
Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate. Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is A, B, and D.These are some of the strategies to prevent orthostatic hypotension, which is a sudden drop in blood pressure caused by a change in posture, such as when a person stands up quickly.
Some explanations for the other choices are:.
• Choice C is wrong because drinking caffeinated beverages can cause dehydration, which can worsen orthostatic hypotension by reducing the fluid volume in the blood vessels.
• Choice E is wrong because increasing salt intake can raise blood pressure, but it can also cause fluid retention, which can strain the heart and kidneys.People with hypertension, heart failure, or kidney disease should limit their salt intake.
Some normal ranges for blood pressure are:.
• Systolic blood pressure (the top number) should be less than 120 mmHg for most adults.
• Diastolic blood pressure (the bottom number) should be less than 80 mmHg for most adults.
• Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 2 to 5 minutes of standing.
Correct Answer is ["A","B","E"]
Explanation
The correct answer isA, B, and E.
The nurse should instruct the patient to do the following:.
• Trim nails straight across and file edges smoothly.
• Soak nails in warm water before trimming to soften them.
• Report any signs of infection or inflammation around nails.
These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.
Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.
To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.
:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.
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