The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility.
Which instructions are appropriate for the nurse to include? Select all that apply.

Choice A rationale

Holding the breath while bearing down is known as the Valsalva maneuver. This action increases intrathoracic and intra-abdominal pressure, which can lead to a sudden drop in heart rate and a subsequent rise in blood pressure when the breath is released. This can be dangerous for clients with cardiovascular disease and does not address the underlying cause of constipation. It is not a recommended technique for promoting healthy or efficient bowel movements.

Choice B rationale

While increasing fluid intake is essential for treating constipation, 1000 milliliters per day is generally insufficient for most adults. Standard recommendations usually suggest at least 2000 to 3000 milliliters of fluid daily to keep the stool soft and facilitate its passage through the colon. Inadequate fluid intake allows the colon to absorb more water from the waste, resulting in hard, dry stools that are difficult and painful to evacuate during defecation.

Choice C rationale

Bananas are often included in the BRAT diet, which is used to manage diarrhea because they can have a binding effect on the stool. While they contain some fiber, they are not the primary fruit recommended for relieving constipation. High-fiber foods like prunes, pears, or leafy greens are more effective at increasing stool bulk and stimulating peristalsis. Relying on bananas might not provide the necessary stimulus to resolve a client's chronic or acute constipation.

Choice D rationale

Physical activity is a primary intervention for constipation because exercise stimulates peristalsis, which is the rhythmic contraction of the intestinal muscles that moves waste through the digestive tract. Even moderate activity, such as walking, can significantly decrease the transit time of stool in the large intestine. This limits the amount of water absorbed by the colon, keeping the stool softer and easier to pass, thereby directly addressing the physiological slowing associated with constipation.

Choice A rationale

Excessive moisture on the skin generally leads to maceration, which appears as white, wrinkled, or softened tissue, not a yellowish tinge. This condition is common in skin folds or under dressings where perspiration or wound exudate is trapped. It does not affect the sclera of the eyes and is localized rather than systemic. Yellowing indicates a biochemical change in the blood chemistry rather than a simple topical reaction to moisture or environmental humidity.

Choice B rationale

While some genetic conditions can cause skin changes, a yellowish tinge in both the skin and the whites of the eyes is a hallmark sign of jaundice rather than a localized lesion. Genetic predispositions like neurofibromatosis or birthmarks cause specific pigmentation patterns, but they do not typically cause the generalized icterus seen in systemic disease. The yellowing described is a result of metabolic failure or biliary obstruction rather than an inherited dermatological lesion or primary skin disorder.

Choice C rationale

Excessive bile deposits, specifically an accumulation of bilirubin in the blood and tissues, cause the yellowish discoloration known as jaundice. Bilirubin is a byproduct of red blood cell breakdown that the liver usually processes and excretes. When the liver is diseased, or the bile duct is obstructed, bilirubin levels rise above the normal range of 0.3 to 1.0 mg/dL. This pigment then settles in tissues with high elastin content, such as the skin and sclera.

Choice D rationale

Excessive fluid loss, or dehydration, usually results in decreased skin turgor, dry mucous membranes, and sunken eyes, but not yellowing. When a client is severely dehydrated, the skin may appear pale or even slightly dusky due to poor perfusion, but the classic yellowing of the sclera is absent. Dehydration affects the volume of the intravascular space but does not cause the accumulation of bile pigments that characterizes the clinical presentation of jaundice or hepatic dysfunction.