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After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
- A. I must clean my rectal area with warm water after each stool and apply zinc oxide ointment.
- B. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel.
- C. I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry.
- D. I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.
Correct Answer: B
Rationale: Toilet paper can irritate sensitive perineal skin, so warm water rinses or a soft cotton washcloth should be used instead. Aloe vera is not effective for protecting skin from the excoriating effects of liquid stools. The other options describe appropriate care to prevent further irritation.
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A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands with hot water before eating.
- B. Cook foods thoroughly, especially poultry and eggs.
- C. Wash your hands before and after using the bathroom.
- D. Avoid eating raw or undercooked eggs and meats.
- E. Refrigerate leftovers promptly to prevent bacterial growth.
Correct Answer: B,C,D,E
Rationale: To prevent Salmonella infection, clients should cook foods thoroughly, wash hands before and after bathroom use, avoid raw or undercooked eggs and meats, and refrigerate leftovers promptly to inhibit bacterial growth. Hot water is not specifically required; soap and water are sufficient.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
- A. Lower gastrointestinal bleeding - Erosion of the bowel wall
- B. Abscesses - Localized pockets of infection develop in the ulcerated bowel lining
- C. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria
- D. Non-mechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer
- E. Fistulas - Dilation and decreased motility caused by paralysis of the colon
Correct Answer: A,B,D
Rationale: Lower GI bleeding results from bowel wall erosion, abscesses form in ulcerated bowel lining, and non-mechanical bowel obstruction occurs due to colon paralysis from colorectal cancer. Toxic megacolon involves colon dilation, not pyuria/fecaluria, and fistulas result from transmural inflammation, not paralysis.
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?
- A. A severe steady right lower quadrant pain.
- B. Abdominal pain associated with nausea and vomiting
- C. Marked peristalsis and hyperactive bowel sounds.
- D. Abdominal pain that increases with knee flexion
Correct Answer: A
Rationale: Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Nausea and vomiting typically indicate gastroenteritis if they occur first. Marked peristalsis and hyperactive bowel sounds are not typical of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
- A. Low-fiber diet
- B. Skin protection
- C. Antibiotic administration
- D. Blood glucose monitoring
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
- A. Heart rate and rhythm
- B. Bowel sounds
- C. Urinary output
- D. Respiratory rate
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.