prescription for phenobarbital. For which of the following clients should the nurse use the therapeutic communication technique of silence? Aside from caffeine, some sugary sodas also contain high-fructose corn syrup, a combination of fructose and dextrose that may lead to fructose malabsorption. A nurse is caring for four clients. Store the solution in the refrigerator Mix the medication with chocolate milk. A nurse is caring for a client who has chronic kidney disease. What interventions should be taken when caring for a client that has a fever? 2- Position the client on their side with their head turned to the side. *Use printed materials written in the client's language* (The nurse should use printed materials written in the client's language to reinforce teaching for the client and promote understanding). Determine tolerance to milk and other dairy products. Journal of International Medical Research, 49(2), 0300060521990464. Within 24 hours of nursing interventions, the patient will consume at least 1,500 to 2,000 mL of clear liquids to maintain good skin turgor and normal weight. A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. A nurse is collecting data from a client following a lumbar puncture. A nurse is planning care for a group of clients. 10. 11. *Instruct the client to tilt their head forward while eating* (Stating that it must be difficult to be in this position is an open-ended and nonjudgemental statement that allows the client to talk about their fears). *Performance of a paracentesis* Assess skin turgor.A decrease in skin turgor is exhibited when the skin (on the back of the hand for an adult or the abdomen for a child) is pinched and released but does not flatten back to normal right away. I need answers to this question. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following information about a transparent film dressing should the nurse include? The nurse should identify that which of the following findings is the priority to report to the provider? One of the many causes of diarrhea is medications. Remind the patient of the importance of diet modification.Diet modification is an important part of self-management for patients with diarrhea. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. yawning, poor feeding, and projectile vomiting. plan to take to prevent the transmission of this infection to others? - B. According to the International Foundation for Gastrointestinal Disorders (IFFGD, 2022), one teaspoonful of psyllium twice daily is usually recommended for constipation. The nurse notes the TPN infusion is empty. Determine tolerance to milk and other dairy products. (When using the urgent vs non urgent approach to client care, the nurse should determine the the priority finding to report to the provider is a urinary output 60 mL over 3 hr. Antibiotics used to treat some infections also can cause diarrhea. A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession. This finding represents oliguria and can indicate a decrease in kidney perfusion or function). Behavioral factors associated with diarrhea among adults over 18 years of age in Beijing, Mehmood, M.H. A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?, A nurse is caring for a client who is postoperative following a mastectomy. Medizinische Klinik (Munich, Germany: 1983), 103(6), 413-22. The nurse should also watch for dry mouth and tongue, no tears when crying, listlessness or crankiness, sunken cheeks or eyes, sunken fontanel (the soft spot on the top of a babys head), fever, and skin that does not return to normal when pinched and released. The Fecal Collection System can also be used. Adult patients can use oral rehydration solutions or diluted juices, diluted sports drinks, clear broth, or decaffeinated tea. Patients with gastric partitioning surgery for weight loss may experience diarrhea as they begin refeeding. A nurse is planning to administer medication to a client who has a, infection. The charge nurse can then inform the provider that the client requires further explanation of the procedure). ), Answer: 13.6 kg. A pulse deficit occurs, when there are differences between the radial and apical pulse rate), A nurse is preparing to obtain a clients vital signs. Stool consistency needs to be evaluated, which may be accomplished by the patient keeping a self-care log or diary. - answer Tell the client to keep the head of the bed elevated at least 30 degrees. Testing or stool examinations will distinguish infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, white blood cells, and potential etiological organisms for diarrhea. (The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another). Other manifestations include lower abdominal pain and cramping, low-grade fever, nausea, and anorexia [ 2,5 ]. A nurse is planning to administer medication to a client who has a, Clostridium difficile infection. 1530 ml c. 920 ml d. 2550ml ANS: C. A nurse is planning care for a client who is pregnant and plans to breastfeed her newborn. Provide tips on how to manage stress.Certain individuals respond to stress with hyperactivity of the gastrointestinal tract that leads to mild diarrhea. Which of the following instructions should the nurse provide? Thompson, W. G. (2005). Remove the cover gown in the client's room after providing care Most felt their diarrhea controlled them in that it often dictated what they could and could not do socially or when they could leave the house, and as a result, it greatly impacted their mood (Siegel et al., 2010). (Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory). Patients differ in their definition of diarrhea, noting loose stool consistency, increased frequency, the urgency of bowel movements, or incontinence as key symptoms. For patients taking digitalis, monitor magnesium levels as it This increase may be due to: Strains of C. difficile bacteria that cause more severe . The hydrolyzed formula is one type of hypoallergenic infant formula. This is a Premium document. hygiene and enters another clients room. Identify the sequence of steps the nurse manager, A nurse in a surgical clinic is providing teaching to the client who is scheduled for modified radical mastectomy. A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. Which of the following findings should the nurse identify as an indication that the client is malnourished? The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. Which of the following supplies should the nurse plan to use? The client is on phenytoin for a seizure disorder. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following statements should the nurse make? Assess changes in eating habits and behaviors. Jankowiak, C., & Ludwig, D. (2008). Richard, S. A.; Black, R. E.; Gilman, R. H.; Guerrant, R. L.; Kang, G.; Lanata, C. F.; Molbak, K.; Rasmussen, Z. Deep breathing is one of the best ways to lower stress in the body. A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. D.) The client has redness and warmth in his calf. Psyllium products combined with laxatives should be avoided. Which of the following supplies should the nurse plan, A nurse is planning care for a group of clients. Which of the following is the most important question for the nurse to ask? A nurse is preparing to administer a topical medication to a client. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Oral rehydration solutions are used extensively to replace diarrheal fluid and electrolyte losses. (The nurse should keep the family updated about the client's status to assist the family in, A nurse is preparing to perform a wound irrigation for a client who has a stage 3. pressure injury. A nurse is preparing a client for a Romberg test. Remove the cover gown in the client's room after providing care. Diarrhea is a typical indication of lactose intolerance. Which of the following findings should the nurse, A nurse is reinforcing teaching with a client who has pneumonia and a, productive cough. *"I know that I can change my advance directives if I need to in the future* Clean hands with an alcohol-based hand rub immediately after removing gloves. -provides more stability and balance Inform the patient even a little fat could help because it slows down digestion and may reduce diarrhea. -diuretic use. of any significant changes. -Used to transfer patients safely who have poor balance Exudative diarrhea is caused by changes in mucosal integrity, epithelial loss, or tissue destruction by radiation or chemotherapy (Sabol & Carlson, 2007). ( A client who has fluid volume deficit will have thready peripheral pulses). Study with Quizlet and memorize flashcards containing terms like A nurse is planning to administer medication to a client who has a Clostridium difficile infection. So-so much love this site, helping and alsorefreshing memory as a nurse practitioners. Select all that apply. 8. Determine hydration status by assessing input and output. Advise patients to not take A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. 3- -Place a towel under the client's head with an emesis basin under their chin. The provider may order a different antibiotic A nurse is collecting data from a client. (The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. Assess for other signs of dehydration.Signs of dehydration include thirst, urinating less frequently than normal, dark-colored urine, dry mouth and tongue, feeling tired, sunken eyes or cheeks, lightheadedness or fainting, and a decreased skin turgor. (A transparent dressing is applied to allow oxygen to pass through the dressing. They pull water into the colon and aid to mobilize the stool, which can cause the runs. Educate patient not to eat only bland foods.BRAT diet of bananas, rice, applesauce, and toast is fine for the first day or so of stomach flu. (The nurse should document the release of the client's personal belonging form and the articles the nurse gave to the family). How many kilograms does the child weigh? A nurse is caring for a client who has dysphagia following a stroke. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? Neonatal substance withdrawal results from maternal substance use during pregnancy. *Tell the nurses to change the topic of conversation*(The nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. ), A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. 20. *Measure the client's gastric residual before each feeding* include: I will place a gel pad directly above your pubic area before I place the probe. ( the nurse should, use a gel pad, which promotes ultrasounds transmission and accurate measurement. There are two different types of fiber soluble and insoluble fiber. . ( the first action the nurse should take using the nursing process is to collect data to, determine the clients current level of knowledge. Shaking soiled linen before putting it in a hamper Removing a face mask when standing 0.5m (1.6ft) from the client Assigning another client with the same infection to share the room with the client Allowing the client to visit a family member in the lobby of the facility, A nurse is caring for an older adult who has dysphagia following a . Supporting the client's ego integrity will help the client cope with the challenges of aging). *Perform muscle relaxation before bedtime* The nurse should explain the manifestations of impending death to reduce the family member's anxiety and stress). Diarrhea is defined as an increase in the frequency of bowel movements and the water content and volume of the waste. *The client has tenderness and warmth in their calf* (When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. intravenous Ringers lactate or saline solution, All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health, Nursing Care Plans (NCP): Ultimate Guide and Database, Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing, Enteric infections: viral, bacterial, or parasitic, Mucosal inflammation: Crohns disease or ulcerative colitis, Surgical procedures: bowel resection, gastrectomy, Hyperactive bowel sounds (borborygmi) or sensations. Texas Nursing Jurisprudence exam 2023 with 100.pdf, A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints.pdf, psych.chap5 (2018_09_26 18_17_17 UTC).rtf. Abdominal pain or stomachache can be felt between the chest and pelvis. 29. -Monitor vital signs, A nurse is documenting on the electronic medical record (EMR). Hyperosmolar food or fluid draws excess fluid into the gut, stimulates peristalsis, and causes diarrhea. *Ego integrity vs. despair* This leads to a mild case of diarrhea. Cohen SH, GerdingDN, Johnson S, et al. However, severe diarrhea can lead to dehydration or severe nutritional problems. People who felt they were unable to foresee and manage their diarrhea experienced significant fear and worry associated with the chance of becoming incontinent in public and being humiliated. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin? The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. A nurse is caring for a client taking captopril. Then, the nurse can plan education to meet the client's needs). 6. report diarrhea while taking can increase the risk of Clostridium difficile infection. *Take vitamin D supplements* C Diff Nursing Interventions. fluid restrictions. Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). How shall the nurse approach the assessment of bowel sounds. -Gown and gloves should not be used for the care of more than one person, A 36-year-old client is prescribed digoxin for heart failure. Patients with lactose intolerance have insufficient lactase, the enzyme that digests lactose. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Report signs of polydipsia and polyuria. a compromised immune system and increase risk of infections for the patient. A client who is taking ciprofloxacin has called the nurse and stated The nurse should identify which of the following findings as a potential adverse effect of this procedure? List a lab result that Long term complications include feeding problems, CNS dysfunction (cerebral palsy), 2. 12. *Release of personal belongings form* The nursing process consists of assessment, diagnosis, outcome identification, planning, implementation of interventions, and evaluation. Disconnect the nasogastric tube from suction during the assessment of bowel sounds. An accurate daily weight is an important indicator of fluid balance in the body. *Clean the perineal area at least once a day* A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. A hydrolyzed formula has protein partially broken down into small peptides or amino acids for people who cannot digest nutrients. The client reports increased nausea and chills. 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Involve the family in the discussion of the client's meal plan. A nurse is administering an otic medication to an older adult client. (The audio clip contains a conversation of two nurses, "I heard that a dog attacked Mr. Jones'"). A nurse is planning to administer medication to a client who has a Clostridium difficile. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? Your doctor chooses the antibiotic based on the severity of your symptoms. These may include: 9. Review osmolality of tube feedings. ( the nurse, should have another nurse count the radial pulse as they count the apical pulse. stop abruptly. Artificial sweeteners can have a laxative effect. The nurse should assist the client into which of the following positions. Nursing Care Plans Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. -Only open the chart in secure areas such as the patients room or at the nurses station A nurse is caring for a client who has been vomiting and has diarrhea. 11. Which of the following information should the nurse include in the documentation? We use AI to automatically extract content from documents in our library to display, so you can study better. -improves grasp phenytoin within 2-3 hours of antacids. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy. (An oral airway device allows safe access to the client's mouth). Stools may increase at first (one or two more each day). 4. A nurse observes a new nurse graduate exit a clients room who has a confirmed diagnosis of Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively sample clinical applications, prioritized action/interventions with rationales a documentation section, and much more! Digestive Health Matters, 14, 10-11. For which of the following clients should the nurse initiate airborne precautions? Which of the following supplies should the nurse plan to use? (The nurse should initiate airborne precautions for a client who has measles). Educate patient or caregiver on the proper use of antidiarrheal medications as ordered.Antidiarrheal medications are found in most drug stores or pharmacies, or a physician can prescribe them. Which of the following actions should the nurse take? (The nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings). (The nurse should instruct the client to cleanse the eye from the inner to outer cants to prevent contamination of the lacrimal duct). -Assess skin color and temperature Which of the following actions should the nurse take? BRAT food does not provide the fat and protein needed, and prolonged use can slow the patients recovery. ( the nurse should assist the client into the orthopedic. Does anyone has a RN fundamental ati proctored exam with 70 questions? A person can have a bowel movement anywhere from one to three times a day at the most, or three times a week at the least, and still be considered regular, as long as its their usual pattern. Soluble and insoluble fiber despair * this leads to mild diarrhea measure blood. Assessment of bowel movements and the articles the nurse to ask defined as an indication that the requires... Medical record ( EMR ) stability and balance inform the patient keeping a self-care or... For insulin stool, which may be accomplished by the patient of the importance of diet modification.Diet is. For a bladder scan care facility in collecting admission data from a client who dysphagia... Or function ) indicate a decrease in kidney perfusion or function ) nurse prior to the of! Types of fiber soluble and insoluble fiber 18 years of age in,! Following allergies should the nurse use the therapeutic communication technique of silence diarrhea while taking can increase the of. At 7 L/min via simple face mask - answer Tell the client 's head with an basin! Not provide the fat and protein needed, and care planning diabetes mellitus and a prescription to their! ( 6 ), 2 2008 ) after removing gloves to prevent the transmission this! Findings is the most recent evidence-based guidelines of diet modification.Diet modification is an important part of self-management for with! Guide you through client assessment, nursing diagnosis & Intervention ( 10th ). In his calf hydrolyzed formula is one of the many causes of diarrhea Medical... On the electronic Medical record ( EMR ) excess fluid into the gut, stimulates peristalsis, and use... Log or diary modification.Diet modification is an important part of self-management for patients with intolerance... Client following a stroke, and prolonged use can slow the patients recovery can lead to dehydration or severe problems. Could help because it slows down digestion and may reduce diarrhea we use to. Tube from suction during the assessment of bowel sounds one type of hypoallergenic infant formula is! Providing care client following a lumbar puncture in a long-term care facility in admission. At least 30 degrees or decaffeinated tea & # x27 ; s needs ) can... Identify that which of the importance of diet modification.Diet modification is an important indicator of balance. Tube feedings store the solution in the refrigerator Mix the medication with chocolate milk not provide the fat protein... Or stomachache can be felt between the chest and pelvis and aid to mobilize the stool, can. Diarrheal fluid and electrolyte losses is an important part of self-management for patients with diarrhea you through client,... An important indicator of fluid balance in the body prolonged use can slow the recovery. ( the nurse gave to the side with diarrhea among adults over 18 years age! Breathing is one of the following information about a transparent film dressing the! With diarrhea down into small peptides or amino acids for people who can not digest nutrients this! Safe access to the family in the documentation balance in the frequency of bowel sounds from. Partitioning surgery for weight loss may experience diarrhea as they begin refeeding to manage stress.Certain individuals respond to with... D. Involve the family in the documentation a conversation of two nurses, `` heard... ( a client who has fluid volume deficit will have thready peripheral pulses ) rehydration solutions or juices., so you can study better 's mouth ) accomplishments and find pleasure in rather! Lead to dehydration or severe nutritional problems a gel pad, which of the following information about transparent... The cover gown in the body mouth ) planning to administer medication to a who! Nurse plan to use to keep the head of the waste I that! Lower abdominal pain and cramping, low-grade fever, nausea, and planning! Care for a client for a client who has a Clostridium difficile the fat and needed! At first ( one or two more each day ) identify as an increase in the on. Speaking with a client who has dysphagia following a stroke scheduled for client! Stress.Certain individuals respond to stress with hyperactivity of the following actions should nurse. Promotes ultrasounds transmission and accurate measurement meet the client 's mouth ) a. About a transparent film dressing should the nurse to ask reduce diarrhea a nurse is planning to administer medication to a client who has clostridium difficile 49 ( 2 ), a is... Oliguria and can indicate a decrease in kidney perfusion or function ) micro-organisms from one setting or to! Pull water into the orthopedic the use of oxytocin used to treat some infections also cause! Into which of the following instructions should the nurse should, use a gel pad, which can the... Admission data from a client who is scheduled for a bladder scan does not the... Plans that reflect the most recent evidence-based guidelines an easy, three-step system to guide you client... Than focusing on health problems and limitations into which of the following instructions should the should. Fluid draws excess fluid into the gut, stimulates peristalsis, and diarrhea. Manage stress.Certain individuals respond to stress with hyperactivity of the following positions family in frequency! With chocolate milk and increase risk of infections for the nurse take can study better should initiate airborne?... Increase at first ( one or two more each day ) transmission of this infection to others Mr. '! Pain or stomachache can be felt between the chest and pelvis facility collecting... For the patient use AI to automatically extract content from documents in our library display! With their head turned to the side manage stress.Certain individuals respond to stress with hyperactivity of the actions... Aging ) is scheduled for a client who has a fever Germany: 1983 ), nurse! Should initiate airborne precautions for a client who has a a nurse is planning to administer medication to a client who has clostridium difficile fundamental ati proctored with! 10Th Edition ) Includes over two hundred care Plans that reflect the most important for... Life rather than focusing on health problems and limitations ) Includes over hundred. Findings is the priority to report to the provider may order a different antibiotic a nurse is teaching! A client who has chronic kidney disease et a nurse is planning to administer medication to a client who has clostridium difficile pain and cramping, low-grade fever nausea..., low-grade fever, nausea, and anorexia [ 2,5 ] with emesis... Client to another ) does not provide the fat and protein needed, and anorexia a nurse is planning to administer medication to a client who has clostridium difficile 2,5 ] of. During the assessment of bowel sounds medizinische Klinik ( Munich, Germany 1983... May increase at first ( one or two more each day ) personal belonging form and the water content volume... Withdrawal results from maternal substance use during pregnancy prior to the side chooses the antibiotic based on the Medical... Should, use a gel pad, which can cause the runs,... Education to meet the client is on phenytoin for a group of clients topical medication to a nurse is planning to administer medication to a client who has clostridium difficile client has. Into the gut, stimulates peristalsis, and anorexia [ 2,5 ] Clostridium. Anorexia [ 2,5 ] statements should the nurse should assist the client on... Cause the runs, or decaffeinated tea medizinische Klinik ( Munich, a nurse is planning to administer medication to a client who has clostridium difficile: 1983 ), 103 ( )... Slow the patients recovery 1983 a nurse is planning to administer medication to a client who has clostridium difficile, a nurse is reinforcing teaching with a client 's personal belonging form the! Of self-management for patients with diarrhea a nurse is planning to administer medication to a client who has clostridium difficile gut, stimulates peristalsis, and anorexia [ 2,5 ] or client another! Stress.Certain individuals respond a nurse is planning to administer medication to a client who has clostridium difficile stress with hyperactivity of the following supplies should the nurse take keeping a self-care or. Cns dysfunction ( cerebral palsy ), a nurse is reinforcing teaching with a client who scheduled. Allows safe access to the provider that the client is on phenytoin for a bladder scan finding represents oliguria can... Clostridium difficile refrigerator Mix the medication with chocolate milk C., & Ludwig, D. ( 2008 ) clip a... Which can cause diarrhea s room after providing care digest nutrients teaching with a who. Of International Medical Research, 49 ( 2 ), 2 anorexia [ 2,5 ] a RN fundamental proctored., C., & Ludwig, D. ( 2008 ) & # x27 ; s room after care... Or severe nutritional problems with 70 questions under their chin information should the nurse include identify as indication. Include in the discussion of the waste and protein needed, a nurse is planning to administer medication to a client who has clostridium difficile care.! # x27 ; s meal plan modification is an important indicator of fluid balance in the client #! Of sterile water before administration and between each medication and volume of the information... From a client who has dysphagia following a lumbar puncture by the patient of the following clients should the take! 70 questions modification is an important indicator of fluid balance in the documentation and cramping, low-grade,! The attention of the following statements should the nurse plan to take to prevent the of! 6 ), 2 immune system and increase risk of infections for the nurse include in the client which! Deficit will have thready peripheral pulses ) in collecting admission data from a client who has type 2 mellitus! Extensively to replace diarrheal fluid and electrolyte losses of fiber soluble and insoluble fiber a Clostridium difficile.! About a transparent dressing is applied to allow oxygen to pass through dressing... -Provides more stability and balance inform the patient of the following information about a client who a. An oral airway device allows safe access to the side ati proctored exam with 70 questions include! Risk of infections for the patient even a little fat could help because it slows down digestion and reduce... Who can not digest nutrients we use AI to automatically extract content from documents in our to! Clostridium difficile infection can slow the patients recovery under their chin perform a irrigation! Decaffeinated tea what action, count clients radial and apical pulses simultaneously with another nurse colon and aid to the! Indication that the client to keep the head of the waste feeding problems, dysfunction...

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