A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury?
a. Rectal skin breakdown
b. Contamination of existing wounds
c. Falls from attempts to reach the bathroom
d. Cross-contamination into the upper GI tract
C
The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.
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