A patient is immobilized after surgery. The nurse observes a continual oozing of stool from the patient's rectum. The nurse recognizes that this condition most likely represents:
A. diarrhea.
B. incontinence.
C. fecal impaction.
D. the Valsalva maneuver.
C
Diarrhea is an increased frequency in the passage of loose stools. Incontinence is the inability to control the passage of urine. The Valsalva maneuver occurs when pressure is exerted to expel feces through a voluntary contraction of the abdominal muscles while maintaining forced expira-tion against a closed airway.
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What should the nurse include in the plan of care to protect the skin integrity of an incontinent patient? (Select all that apply.)
a. Immediately remove wet garments and linens. b. Wash skin with an antiseptic and towel dry. c. Inspect for areas of redness and break-down every morning. d. Apply cornstarch to the perineum to ab-sorb moisture. e. Apply protective creams per agency poli-cy.
An older person reports hearing whistling in both ears when no external sounds are present and is diagnosed with tinnitus. Which of the following are causes of tinnitus? (Select all that apply.)
a. Exposure to loud noises b. Use of a hearing aid c. Cerumen buildup d. Side effects of medications e. Age-related changes in the middle and inner ear
A patient is prescribed RICE therapy. How should the nurse describe the components of this therapy?
1. rest, ice, compression, and elevation 2. rest, ice, CT scan, and elimination of pain 3. rest, immobilization, CT scan, and elimination of pain 4. rest, immobilization, compression, and elevation
The nurse teaches the family of an AIDS client about managing symptomatic illness by preventing deteriorating conditions, such as diarrhea, skin breakdown, and inadequate nutrition. This nursing intervention is an example of _____ prevention
a. Primary b. Secondary c. Tertiary d. Primary health care