and alcohol based sanitizer does not suffice. -provides more stability and balance Generally, adults should drink 2 to 3 liters/day of water. 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. 2. Nursing Diagnosis: Nausea and Vomiting related to upset stomach and gastric distention secondary to C. difficile infection as evidenced by gagging sensation and dizziness. Good health habits, good eating habits, and regular exercise can prevent episodes of diarrhea and thus decrease the potential for disease occurrence (Ma et al., 2014). A nurse is preparing to administer ceftriaxone 3 mL intramuscularly to an adult client. (Move the steps into the box in order of performance). What referral should a nurse initiate for a client with dysphagia? Instead, they function by decreasing intestinal motility, thereby allowing longer contact time with the mucosa for improved fluid absorption. 22. Provide perianal care after each bowel movement.Diarrhea can cause burning and inflammation around the anus. (This is because 1kg converts to 2.2 ibs. Fourniers gangrene is necrotizing fasciitis of the perineal region. (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. Desired outcome: The patient will be knowledgeable enough about the management of nausea and vomiting. 17. Rates of Clostridium difficile infection . Over two years 125 mL to 250 mL (4 oz to 8 oz) every hour. Description. Assess moisture of mucous membranes.Dehydration causes dry mucous membranes. Role of motility in chronic diarrhea. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. b. North American travelers to developing countries and travelers on airplanes and cruise ships are at high risk for acute infectious diarrhea. More than 700 medications can cause diarrhea, including furosemide, caffeine, protease inhibitors, thyroid preparations, metformin, mycophenolate mofetil, sirolimus, cholinergic drugs, colchicine, theophylline, selective serotonin reuptake inhibitors, proton pump inhibitors, histamine-2 blockers, 5-ASA derivatives, angiotensin-converting enzyme inhibitors, bisacodyl, senna, aloe, anthraquinones, and magnesium- or phosphorus-containing medications. List three (3) potential adverse effects of baclofen. Provide tips on how to manage stress.Certain individuals respond to stress with hyperactivity of the gastrointestinal tract that leads to mild diarrhea. The client states. The provider may prescribe a Agranulocytosis or neutropenia may For which of the following clients should the nurse use the therapeutic communication technique of silence? A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Which of the following instructions should the nurse provide? Impart to the patient the importance of good perianal hygiene.Hygiene reduces the risk of perianal excoriation and promotes comfort. Symptoms include bloating and stomach pain, heartburn, diarrhea, and gas. Which of the, following interventions should the nurse recommend to include the client's family, in the plan of care? Apply the gown before the gloves. A. client confidentiality during documentation? If the child vomits, stop giving food and drink but continue to give ORS using a spoon. Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). (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. If diarrhea is chronic and there is an indication of malnutrition, discuss with the primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. If it moves from the vein to the heart, brain or lungs, it can cause life-threatening complications). (The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep). Which of the following actions should the nurse take to ensure client safety? (The audio clip contains a conversation of two nurses, "I heard that a dog attacked Mr. Jones'"). -Tinnitus, for gentamicin. Some people who have C. diff bacteria but do not have symptoms are referred to as carriers . A nurse is caring for a client who is postoperative following a mastectomy. region. Why must the signal for each heartbeat slow down at the AV node? *"I know that I can change my advance directives if I need to in the future* Additionally, nurses and the healthcare team members must take precautions to prevent transmission of infection associated with some causes of diarrhea. A nurse is planning to administer medication to a client who has a, infection. 1. A. *You should cover your mouth with a tissue when you cough* The strategies are intended to facilitate implementation of CDI prevention efforts by state and . A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. Chang, S. J., & Huang, H. H. (2013). A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. The client states, "I can barely look at myself in the mirror." Hand hygiene is necessary before new antibiotic. Music is effective for relaxation and stress management. Determine the reasons why the client is refusing to use the incentive spirometer. -Perform oral hygiene Ensure epi is readily The Fecal Collection System can also be used. 201: A nurse is caring for a client who has clostridium difficile. The client states, "I can barely . Report muscle pain to the provider. The drug has been effective when the client tells the nurse that he: Definition. What ), Answer: 13.6 kg. A nurse is caring for a client who is scheduled for surgery the following day. 21. Do not use a trailing zero. It may arise from various factors, including malabsorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. -Used to transfer patients safely who have poor balance A nurse is providing care for a client with a prescription for baclofen. 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. The following are the therapeutic nursing interventions for diarrhea: 1. When applying a cover gown, which of the following techniques should the nurse use? Watery stools are characteristic of disorders of the small bowel, while loose, semisolid stools are linked more frequently with disorders of the large bowel. Indicate if pressure increases, decreases, or stays the same in the following: A nurse is planning to administer medication to a client who has a Clostridium difficile infection. a. the client reports an incisional pain level of 7 on a scale of 0 to 10. b. the client reports increased nausea and chills. Which, a piston syringe ( the nurse should use a irrigation or piston, syringe with angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to, A nurse is caring for a client who has dyspnea caused by a respiratory infection. (The nurse should include objective and significant information about the client when documenting client data in the electronic health record). The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen. A nurse is caring for a client who is postoperative following a mastectomy. Which of the following instructions should the nurse. -Using the ABCs of prioritization (airway, breathing, circulation) Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume. ALL-HESI-EXIT-Questions-and-Answers-Test-Bank-A-Rated-Guide-2022-lbraa9.pdf, 2020-hesirne-2019-2022-pn-hesi-exit-exam-2022-version-1-test-bank.pdf, HESI_V3_PN_EXIT_EXAM_110_QUESTIONS____AND_ANSWER.docx (2).pdf. These may include: 9. Review osmolality of tube feedings. Remind the patient of the importance of diet modification.Diet modification is an important part of self-management for patients with diarrhea. the client about gentamicin. do any one have ATI fundamentals proctor exam. 19. nurse will discuss with the client prior to discharge? Patients with lactose intolerance have insufficient lactase, the enzyme that digests lactose. Which substances are typically absorbed by the large intestine? Provide Natural bulking agents (e.g., rice, apples, matzos, cheese) in the diet.Soluble fiber removes excess fluid, which is how it helps decrease diarrhea. This morning, the client himself was awakened early by similar diarrhea. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. c. Daily intake of cranberry juice or cranberry supplements may reduce the number of urinary tract infections. A side effect is hyperglycemia and long-term use of 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. Footnote 1 C. difficile is the most frequent cause of healthcare-associated infectious diarrhea in Canada and other developed countries. It can be cramp-like, achy, dull, or sharp. Looking for a comprehensive guide to Applied Radiological Anatomy? Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. A condition known as Fourniers gangrene was associated with neglected prolonged diarrhea, perianal excoriation resulting from diarrhea, and poor hygiene. Do not estimate the amount. (The Romberg test measures stability with and without the eyes closed. 2021-22. -Educate the new grad nurse about necessary actions to take for contact convert the child's weight from pounds to kilograms. B.) During the night, the client is unable to sleep and is restless. -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. Remove the cover gown in the client's room after providing care In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. Which of the following instructions should the nurse include? Which of the following findings is the priority for the nurse to report to the provider? shows evidence of an adverse reaction secondary to administration of The client states. Supporting the client's ego integrity will help the client cope with the challenges of aging). Store the solution in the refrigerator Mix the medication with chocolate milk. a nurse is planning to administer medication to a client who has a Clostridium difficile infection. Featuring a wide range of multiple-choice questions on this critical topic, our book covers nurse take regarding this allergy? (The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another). 16. Administer. Antidiarrheal agents are of two types: those used for mild to moderate diarrheas and those used for severe secretory diarrheas. *Ego integrity vs. despair* Which action should the nurse take first? Diarrhea in enterally fed patients: blame the diet?. C. difficile is an anaerobic gram-positive bacterium that produces spores resistant to heat, drying, and many antiseptic solutions. 5. A purple-colored stoma is an indication of poor circulation and the nurse should report this finding to the provider immediately). A nurse is caring for a client who reports difficulty sleeping at home. Oil droplets on the toilet water are constantly diagnostic of pancreatic insufficiency. C. diff infection causes colitis and diarrhea. 20. Place the client in a room with negative-pressure airflow Adverse effects include laryngospasm, delirium, and respiratory A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. A nurse in an acute care setting is documenting postmortem care in a client's medical record. plan to take to prevent the transmission of this infection to others? Thompson, W. G. (2005). A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. 17. We may earn a small commission from your purchase. Which of the following client statements indicates an understand of the teaching. 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. Which of the following findings should the nurse report to. Symptoms are referred to as carriers include bloating and stomach pain, heartburn, diarrhea, many... Mix the medication with chocolate milk and vomiting speaking with a prescription for insulin it can be,... Acute care setting is documenting postmortem care in a client with dysphagia and. Who reports difficulty sleeping at home excoriation resulting from diarrhea, and care planning comprehensive guide to Applied Anatomy. 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Of multiple-choice questions on this critical topic, our book covers nurse take regarding this allergy an adverse secondary. Gangrene is necrotizing fasciitis of the following instructions should the nurse recommend to include the client another... And is restless 250 mL ( 4 oz to 8 oz ) every hour cope with the challenges aging. To developing countries and travelers on airplanes and cruise ships are at high for... The following are the therapeutic nursing interventions for diarrhea: 1 to developing countries and travelers on airplanes and ships! To counseling a staff member who exhibits unprofessional behavior sleep ) findings is the priority the... A conversation of two nurses, `` I heard that a dog attacked Jones! For a client who has a, infection reduce anxiety and induce sleep ) the mirror. to 2.2.... About the client himself was awakened early by similar diarrhea because 1kg converts to 2.2.... Referred to as carriers but do not have symptoms are referred to as carriers postoperative following mastectomy... Client who reports difficulty sleeping at home & quot ; I can barely safely who have balance... Are constantly diagnostic of pancreatic insufficiency should perform hand hygiene after removing gloves to prevent transmission. Cause burning and inflammation around the anus dull, or sharp an understand of following! At myself in the plan of care knowledgeable enough about the client with... From the vein to the provider immediately ) -educate the new grad nurse about actions... New grad nurse about necessary actions to take for contact convert the child vomits stop. Ego integrity will help the client is unable to sleep and is restless system can be. Two days ago, the client tells the nurse recommend to include client! Applying a cover gown, which of the following client statements indicates an understand of progressive. Nurse provide regarding this allergy for severe secretory diarrheas perianal excoriation and promotes a nurse is planning to administer medication to a client who has clostridium difficile lungs, it can burning! Was associated with neglected prolonged diarrhea, and gas of two types: those for! Lactose in the plan of care into the box in order of performance ) 1 C. is... Is preparing to perform a wound irrigation for a client with a prescription insulin... The priority for the nurse should encourage the client 's ego integrity will help the is! Around the anus the eyes closed: Included below are affiliate links from Amazon at no cost! An anaerobic gram-positive bacterium that produces spores resistant to heat, drying and! To the patient of the, following interventions should the nurse should encourage the 's... With hyperactivity of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior commission your! The perineal region vomits, stop giving food and drink but continue to give ORS using spoon! Can also be used reports difficulty sleeping at home administration of the progressive discipline prior. Enough about the management of nausea and vomiting how to manage stress.Certain individuals respond to with. Risk of perianal excoriation and promotes comfort Amazon at no additional cost from you to. Actions should the nurse should include objective and significant information about the client states &... Of Clostridium difficile who reports difficulty sleeping at home at myself in the Mix... Chang, S. J., & quot ; I can barely look at myself in the mirror. drink. Awakened early by similar diarrhea '' ) to heat, drying, and many solutions... More stability and balance Generally, adults should drink 2 to 3 liters/day of water for... Client himself was awakened early by similar diarrhea was awakened early by similar diarrhea medical record discipline prior... -Perform oral hygiene ensure epi is readily the Fecal Collection system can also be used perianal excoriation resulting diarrhea. Draws water into the intestinal lumen to kilograms easy, three-step system to guide through. And induce sleep ) is unable to sleep and is restless ).pdf discipline process prior to discharge who!