The nurse identifies a client problem of impaired skin integrity related to diarrhea for a client who has ulcerative colitis. The nurse recognizes that teaching about perianal care has been effective when the client:
cleans and dries the perianal area after each diarrheal stool.
uses alcohol compresses to provide relief from anal irritation.
asks for antidiarrheal medication after each stool.
takes an hour-long Sitz bath following each stool.
The Correct Answer is A
A. Cleans and dries the perianal area after each diarrheal stool: This is the correct option. Effective perianal care for a client with diarrhea, such as ulcerative colitis, involves gentle cleansing and thorough drying of the perianal area after each stool. Proper hygiene helps prevent skin breakdown and irritation caused by prolonged contact with stool.
B. Alcohol can be irritating to the skin and may exacerbate perianal irritation and discomfort. Therefore, using alcohol compresses is not considered an appropriate perianal care practice.
C. While antidiarrheal medications may be prescribed for clients with ulcerative colitis to help manage symptoms, asking for medication after each stool is not a typical or recommended approach. The frequency and timing of antidiarrheal medication administration should be based on healthcare provider recommendations and individual symptom management plans.
D. While Sitz baths can provide relief from perianal discomfort and promote healing, taking an hour-long Sitz bath after each stool may be impractical and excessive. Sitz baths are typically recommended for shorter durations (e.g., 10-20 minutes) and may be used periodically rather than after every stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Protein is essential for tissue repair and maintenance, especially after surgery. Adequate protein intake can also help preserve muscle mass and promote satiety, which can be beneficial for weight management. However, it's important to choose lean protein sources and monitor portion sizes to avoid overconsumption.
A. After gastric banding (Lap-band) surgery, it is generally recommended to avoid high-fat foods. High-fat foods can contribute to weight gain and may increase the risk of complications such as dumping syndrome, which occurs when food moves too quickly from the stomach to the small intestine.
B. Adequate fiber intake is important for promoting bowel regularity and preventing constipation, which can be a concern after gastric banding surgery. However, it's essential to choose low-calorie, high-fiber foods to avoid overeating and to support weight loss goals.
D. After gastric banding surgery, it's generally recommended to avoid drinking fluids with meals. Consuming fluids during meals can cause the stomach pouch to fill too quickly, leading to discomfort and potentially stretching the pouch over time. It's typically advised to wait at least 30 minutes to 1 hour after meals before drinking fluids.
Correct Answer is B
Explanation
B. Rebound tenderness on abdominal palpation: Rebound tenderness, where pain increases upon release of pressure during abdominal palpation, is a classic sign of peritonitis, which can occur due to a peptic ulcer perforation. It indicates irritation of the peritoneum, the lining of the abdominal cavity, which can occur when stomach contents leak into the peritoneal cavity.
A. Numbness in the legs is not typically associated with perforation of a peptic ulcer. Perforation of a peptic ulcer usually presents with localized abdominal symptoms rather than symptoms in the legs.
C. Projectile vomiting of undigested food is not typically associated with perforation of a peptic ulcer. It is more commonly seen in conditions such as pyloric stenosis or gastrointestinal obstruction.
D. Jaundice, a yellow discoloration of the skin and sclera, is not typically associated with perforation of a peptic ulcer.
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