The greatest risk for injury for a client who has fecal incontinence is:
1. Perineal and rectal skin breakdown
2. The contamination of existing wounds
3. Falls resulting from attempts to reach the bathroom
4. Cross-contamination into the upper gastrointestinal tract
ANS: 1
Fecal incontinence is a potentially dangerous condition in terms of contamination and risk for skin ulceration. The greatest risk to the otherwise healthy individual is skin breakdown. Although the other options may be risk factors, they are not as great as that of skin breakdown.
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Which of the following best describes how the Health Planning Model for care of aggregates differs from the customary nursing process applied to the care of an individual?
a. The nurse must be aware of age, gender, race, ethnic group, religion, educational background, occupation, and marital status of the aggregate. b. The nurse must first decide on and define the aggregate to receive care. c. The nurse must determine how best to ensure that each participant receives an equal number of services. d. The nurse must choose which health care need should have first priority.
A patient is receiving chemotherapy for cancer. The nurse reviews the laboratory data and notes that he has thrombocytopenia. Which nursing diagnosis should be given the highest priority?
A) Activity intolerance B) Impaired tissue integrity C) Impaired oral mucous membranes D) Ineffective tissue perfusion (cerebral, cardiopulmonary, GI)
The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client?
Select all that apply. A) Recommending dark sunglasses B) Placing cold eye compresses C) Contacting the client's school nurse D) Performing careful hand hygiene E) Administering antiviral therapy
It is important to assess the educational level of patients primarily to
a. have a complete profile of the patient for your records. b. ascertain the patient's level of understanding of science and health-related concepts. c. determine the patient's ability to comprehend verbal or written instructions about health care. d. decide how much information you should provide.