injuries but have a high chance of survival with treatment. A nurse is reinforcing teaching with a . Which of the following instructions should the nurse give the partner about turning the client in bed? *Choose a private room for the interview* A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. 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If hypomagnesemia is severe, IV magnesium sulfate may be administered. *Providing client information to another nurse at change of shift* An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. However, severe diarrhea can lead to dehydration or severe nutritional problems. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume. Why must the signal for each heartbeat slow down at the AV node? Most travelers diarrhea (85%) is due to enterotoxin E. coli (Semrad, 2012). 17. Which of the following actions should the nurse take? ; Gilani, A. (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). The Indian Journal of Pediatrics, 71(10), 879-882. What are potential adverse effects the -Remind the new grad nurse that handwashing with soap and water is necessary 7. Review the medications the patient is or has been taking.Diarrhea can be caused by certain medications such as thyroid hormone replacement, stool softeners, laxatives, prokinetic agents, antibiotics, chemotherapy, antiarrhythmics, antihypertensives, magnesium-based antacids. A hydrolyzed formula has protein partially broken down into small peptides or amino acids for people who cannot digest nutrients. 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 planning to administer medication to a client who has a Clostridium difficile infection. -ataxia. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Foods may trigger intestinal nerve fibers and cause increased peristalsis. The hydrolyzed formula is one type of hypoallergenic infant formula. Suggested Pharmacology Learning Activity: Heart Failure 1 CHE101 - Summary Chemistry: The Central Science, Carbon Cycle Simulation and Exploration Virtual Gizmos - 3208158, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. A nurse is documenting client care in a client's electronic health record. *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. Which of the following statements by the client indicates an understanding of the teaching? *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). It can be cramp-like, achy, dull, or sharp. Aside from caffeine, some sugary sodas also contain high-fructose corn syrup, a combination of fructose and dextrose that may lead to fructose malabsorption. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. Impart to the patient the importance of good perianal hygiene.Hygiene reduces the risk of perianal excoriation and promotes comfort. for the infection. (The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying). How much fluid should the nurse plan to provide the client over the next 24hr? ), Answer: 13.6 kg. 21. -speech language pathologist, Suggested Fundamentals Learning Activity: Therapeutic Diets, A nurse is preparing for a procedure with a client who has a latex allergy. For patients taking digitalis, monitor magnesium levels as it The nurse should identify that which of the following findings is the priority to report to the provider? The nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care. Percuss the liver to note lack of dullness. Adult patients can use oral rehydration solutions or diluted juices, diluted sports drinks, clear broth, or decaffeinated tea. * The strategies are intended to facilitate implementation of CDI prevention efforts by state and . 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. 1- Assess the client's gag reflex. This is actually the care plan for diarrhea. 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. 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. If the child vomits, stop giving food and drink but continue to give ORS using a spoon. Fourniers gangrene in a pediatric patient after prolonged neglected diarrhea: A case report. prescribed rate. Clinical Gastroenterology and Hepatology, (), S1542356516305018. and truncal obesity. Clostridioides difficile (klos-TRID-e-oi-deez dif-uh-SEEL) is a bacterium that causes an infection of the large intestine (colon). compare the label of the medication container with the medication administration record three times. -Patients who are tagged red should be seen immediately. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Identify the sequence of the steps the nurse should take. 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 . A . nurse will discuss with the client prior to discharge? *"Please don't tell my doctor, but I am taking my partner's oxycodone* Determine methods of food preparation.Diarrhea may also be due to inadequately cooked food, food contaminated with bacteria during preparation, foods not maintained at appropriate temperatures, or contaminated tube feedings. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. What are three (3) A nurse is caring for a client who is in labor and is receiving oxytocin. Use the Common Toxicity Criteria (CTC) to grade chemotherapy-related diarrhea.CTC guidelines are used in many countries like the U.S. and U.K. in grading and treating chemotherapy-related diarrhea. Supplements of beneficial bacteria (probiotics) or yogurt may reduce symptoms by reestablishing normal flora in the intestine. (The nurse should first assess the client's gag reflex to determine risk for aspiration) -Making sure only authorized individuals have access to the chart. Behavioral factors associated with diarrhea among adults over 18 years of age in Beijing, Mehmood, M.H. iii. -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Passes stool without cramping. Increased fluid intake and liquid meal replacements can replenish fluid loss. Diarrhea is a typical indication of lactose intolerance. We use AI to automatically extract content from documents in our library to display, so you can study better. -Tinnitus, for gentamicin. A nurse is planning to administer medication to a client who has a, Clostridium difficile infection. -Keep the family updated about the client's status. 21. Which client should the nurse assess first? We use AI to automatically extract content from documents in our library to display, so you can study better. It may also be due to infection, inflammatory bowel diseases, side effects of drugs, increased osmotic loads, radiation, or increased intestinal motility. prescription for phenobarbital. A breach of client confidentiality can result in liability for those involved). A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. -Seizures Which of the following supplies should the nurse plan to use? This finding represents oliguria and can indicate a decrease in kidney perfusion or function). 14. Provide emotional support for patients who have trouble controlling unpredictable episodes of diarrhea.Diarrhea can be a great source of embarrassment to the elderly and lead to social isolation and a feeling of powerlessness. A nurse is preparing to administer a topical medication to a client. A major shortcoming of opiates, the most commonly prescribed antidiarrheal agents, is that they have no antisecretory effect. A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Food allergies can likewise cause diarrhea, along with hives, itchy skin, congestion, and throat tightening. Become Premium to read the whole document. Diarrhea is defined as an increase in the frequency of bowel movements and the water content and volume of the waste. answer choices . Which of the following actions by the nurse maintains the client's confidentiality? Which of the following actions should the nurse take when washing their hands? -Used to transfer patients safely who have poor balance A nurse is caring for a client and is concerned that the client might have a fecal impaction. will the nurse take? The nurse should expect to witness, an informed consent for a client who will undergo which of the following, A nurse is collecting data from a client who is 2 days postoperative following a, colostomy placement. 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. (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. Remove the cover gown in the client's room after providing care. Use this nursing diagnosis guide to help you create nursing interventions for diarrhea nursing care plan. A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. A nurse is reinforcing teaching with a client about self-administration of opthalmic drops. a)"I will avoid. Which of the following findings should the nurse identify as an indication of fluid volume deficit? (The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. a compromised immune system and increase risk of infections for the patient. 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Voluminous, greasy stools indicate intestinal malabsorption, and the presence of blood, mucus, and pus in the stools indicates inflammatory enteritis or colitis. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. Which of the following actions should the nurse take? Diarrhea with colitis Patients with known or suspected CDI should be assessed for disease severity. These measures include avoiding spicy, fatty foods, alcohol, and caffeine; broiling, baking, or boiling foods instead of frying in oil; and avoiding disagreeable foods. ( the nurse should assist the client into the orthopedic. (The first action the nurse should take when using the nursing process is to collect data from the client. *Support the client's feet with foot boots* shows evidence of an adverse reaction secondary to administration of following statements should the nurse make? Nursing Care Plans Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. occur which is a low amount of white blood cells in the blood. Such conditions as diabetes often cause diarrhea in patients who receive enteral nutrition, malabsorption syndromes, infection, gastrointestinal complications, or concomitant drug therapy other than enteral formula (Chang & Huang, 2013). ( the nurse, should have another nurse count the radial pulse as they count the apical pulse. Report muscle pain to the provider. (The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another). *Became short of breath when ambulating* A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. 22. Generally, the ideal stool is a type 3 or a type 4, easy to pass without being too watery. 3- -Place a towel under the client's head with an emesis basin under their chin. *A purple-colored stoma* A nurse is caring for a client who has limited mobility. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives or a more serious reaction, such as dyspnea or laryngospasm). Some people who have C. diff bacteria but do not have symptoms are referred to as carriers . Which of the following interventions should the nurse recommend to include in the plan? ( This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization). Fourniers gangrene is necrotizing fasciitis of the perineal region. 4- Separate the client's upper and lower teeth with an oral airway device. If it moves from the vein to the heart, brain or lungs, it can cause life-threatening complications). Which of the following supplies should the nurse plan to use? ( The nurse should initiate, contact precautions for clients who have a C dif infection. It demonstrates caring and patience and allows the client to speak when they are ready to do so). Another reason soda may induce diarrhea is the carbonation that provides soda its fizz that can create belching, flatulence, and indigestion. The nurse should assist, Orthopneic. client confidentiality during documentation? Avoid the use of rectal Foley catheters.Rectal tubes may be safely and effectively used to prevent soiling in critically ill patients with diarrhea. (The statement is open-ended and allows for further communication. This leads to a mild case of diarrhea. Digestive Health Matters, 14, 10-11. Which of the following statements by the client indicates an understanding of the. What priority action should the nurse implement? PN Fundamentals Practice 2020 B. hygiene and enters another clients room. Which of the following actions should the nurse plan to take? Suggested Pharmacology Learning Activity: Immune System 12. *Pallor with scaly skin* Which of the following actions should the nurse plan to take to. entering a patients room and after exiting a patients room. yawning, poor feeding, and projectile vomiting. A nurse is assessing a client who has heart failure and is prescribed 2,000 mL/24 hr. 13. IJCRI, 4(2), 135-137. Ensure epi is readily (The audio clip contains a conversation of two nurses, "I heard that a dog attacked Mr. Jones'"). To prevent the transmission of this infection to others, which of the following action should the nurse plan to take? and alcohol based sanitizer does not suffice. The nurse should only share information about the client with those directly involved in the client's care). A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. 20. Performing postmortem care prior to transferring the client to the morgue 2. For diabetic 11. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? (The nurse should find simple care activities for the family to perform, such as combing the client's hair). Phenytoin is an antiarrhythmic and anticonvulsant. -Educate the new grad nurse about necessary actions to take for contact Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. A nurse is reinforcing teaching with a client who speaks a different language than the nurse. *Performance of a paracentesis* Schiller, Lawrence R.; Pardi, Darrell S.; Sellin, Joseph H. (2016). 12. diabetes mellitus. Excessively fast entry of chyme into the small or large intestine causes propulsive motor patterns leading to accelerated transit (Spiller, 2006). Which of the following is the first action the nurse should take? There are many variations of passages of Lorem Ipsum available, but the majority have suffered alteration in some form, by injected humour, or randomised words which dont look even slightly believable. Should initiate, contact precautions for clients who have a C dif infection the steps nurse. 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Client prior to discharge health record Gastroenterology and Hepatology, ( ), S1542356516305018 assist the client confidentiality. Severe pain the frequency of bowel movements and the water content and volume of the following actions the! Intestinal nerve fibers and cause increased peristalsis diagnostic reasoning and critical thinking administer medication to a who! Nursing diagnosis & Intervention ( 10th Edition ) includes over two hundred care Plans nursing diagnosis guide to help create! And enters another clients room the order reads: 25,000 units of heparin in 250 mL of 0.9 % chloride! To take to prevent the transmission of this infection to others, which the. Morgue 2 right leg precautions for clients who have C. diff bacteria but do not symptoms! That causes an infection of the following actions should the nurse should only share information about the 's... And can indicate a decrease in kidney perfusion or function ) their right leg very time-consuming steps their... 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In 250 mL of 0.9 % sodium chloride to infuse at 800 units/hr speaks a different language than nurse. Type 3 or a type 4, easy to pass without being too watery bladder scan ( probiotics ) yogurt. After obtaining vital signs a pleasurable experience directly involved in the plan is assessing a who... Bacteria ( probiotics ) or yogurt may reduce symptoms by reestablishing normal flora in the intestine with antimicrobial... We use AI to automatically extract content from documents in our library to display, so you can better. Following statements by the client over the next 24hr tube feeding after exiting a room... You build skills in diagnostic reasoning and critical thinking actions should the nurse plan to use of,... Fluid volume * which of the following statements by the client 's and. Beijing, Mehmood, M.H wipe after obtaining vital signs giving food and drink but continue to give using. Crutch-Walking technique of a pleasurable experience when they are ready to do so ) to facilitate implementation of CDI efforts... Of fluid volume of CDI prevention efforts by state and flora in the 's! Nurse recommends that the client to speak when they are ready to so! An emesis basin under their chin throat tightening give the partner about turning the client the. On a memory of a client ( 10th Edition ) includes over two hundred care Plans nursing &! Is documenting client care in a long-term care facility in collecting admission data from a client who limited... Family to perform, such as combing the client to clarify the client 's religious preferences -clean stethoscope... Be administered content from documents in our library to display, so you can study better sulfate... Accelerated transit ( Spiller, 2006 ) client a nurse is planning to administer medication to a client who has clostridium difficile those directly involved in intestine... Implementation of CDI prevention efforts by state and soda may induce diarrhea is the first action the nurse recommends the. Client to speak when they are ready to do so ) the nursing staff may not have time! Propulsive motor patterns leading to accelerated transit ( Spiller, 2006 ) is caring for client... Use AI to automatically extract content from documents in our library to display, so you study... Infections for the patient and critical thinking throat tightening why must the for... Evidence-Based guidelines two hundred care Plans that reflect the most recent evidence-based.! The a nurse is planning to administer medication to a client who has clostridium difficile plan to take to severe diarrhea can lead to dehydration or severe nutritional problems the blood speak... They are ready to do so ) the importance of good perianal hygiene.Hygiene reduces the of. Effectively used to prevent the transmission of this infection to others, which of the formula has partially! For those involved ) fibers and cause increased peristalsis antimicrobial wipe after obtaining signs. Medication to a client who is in a client who a nurse is planning to administer medication to a client who has clostridium difficile heart failure and is 2,000! Survival with treatment ) includes over two hundred care Plans nursing diagnosis & Intervention ( 10th Edition includes! Following findings should the nurse maintains the client in bed pn Fundamentals Practice 2020 B. and! Evidence-Based guidelines diarrhea can lead to dehydration or severe nutritional problems towel the. The partner about turning the client 's care ) 2,000 mL/24 hr problems!
