4. Such conditions as diabetes often cause diarrhea in patients who receive enteral nutrition, malabsorption syndromes, infection, gastrointestinal complications, or concomitant drug therapy other than enteral formula (Chang & Huang, 2013). Other nursing diagnoses you could use may include Deficient Fluid Volume, Acute Pain (if stomach cramping is present), or Risk for Infection. maintaining good dental hygiene to prevent gingival hyperplasia. *Actual loss* The client tells the nurse that they have numerous allergies. Evaluation of defecation pattern will help direct treatment, especially for cancer-related diarrhea. Role of motility in chronic diarrhea. dosages of insuling accordingly. (The nurse should document 3+ pitting edema when there is a deep indentation of the tissue, which Is about 6mm). Evaluate dehydration by observing skin turgor over the sternum and inspecting for longitudinal furrows of the tongue. provide to this client? Other manifestations include lower abdominal pain and cramping, low-grade fever, nausea, and anorexia [ 2,5 ]. The drug has been effective when the client tells the nurse that he: Definition. *Support the client's feet with foot boots* *An employer completing a pre-employment screening* Diarrhea with colitis Patients with known or suspected CDI should be assessed for disease severity. *Notify the charge nurse of the client's concerns* clients? nurse will discuss with the client prior to discharge? Store the solution in the refrigerator Mix the medication with chocolate milk. Evaluate the appropriateness of protocols for bowel preparation based on age, weight, condition, disease, and other therapies. report diarrhea while taking can increase the risk of Clostridium difficile infection. Diarrhea is a typical indication of lactose intolerance. Inform the patient even a little fat could help because it slows down digestion and may reduce diarrhea. A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. This is actually the care plan for diarrhea. Generally, the ideal stool is a type 3 or a type 4, easy to pass without being too watery. answer choices . 5. A nurse hears various alarms sounding from different client rooms. The provider may prescribe a Six to 24 months 90 mL to 125 mL (3 oz to 4 oz) every hour. 1530 ml c. 920 ml d. 2550ml ANS: C. A nurse is planning care for a client who is pregnant and plans to breastfeed her newborn. 4. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? A study demonstrated that psyllium husk (Ispaghula) has a gut-stimulatory effect, mediated partially by muscarinic and 5-HT4 receptor activation, which may complement the laxative effect of its fiber content, and a gut-inhibitory activity possibly mediated by blockade of Ca2+ channels and activation of NO-cyclic guanosine monophosphate pathways. (The nurse should document information using an objective description, putting the client's exact words in quotation marks). Which of the following is the proper crutch gait for this client? 4. The nursing process consists of assessment, diagnosis, outcome identification, planning, implementation of interventions, and evaluation. ( the nurse should assist the client into the orthopedic. *Tighten your stomach muscles* A.; Sack, R. B.; Valentiner-Branth, P.; Checkley, W. (2013). f. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. *It must be difficult facing this type of surgery* you take (2003). A. All amounts must be measured and recorded in milliliters. Identify the sequence of steps the nurse manager, A nurse in a surgical clinic is providing teaching to the client who is scheduled for modified radical mastectomy. DTRs frequently and have calcium gluconate available to reverse effects of (Move the steps into the box in order of performance). The newly nurse graduate uses alcohol-bases cleanser to perform hand hygiene and enters another clients room. The client states he is . What action should the (Round the answer to the nearest, tenth. If the patient falls under types 5, 6, and 7, the patient tends toward diarrhea. What referral should a nurse initiate for a client with dysphagia? A nurse receives change- of-shift report on 4 clients . Which of the following interventions should the nurse recommend to include in the plan? Which of the following findings should the nurse identify as an indication that the client is malnourished? A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. (The nurse should keep the family updated about the client's status to assist the family in, A nurse is preparing to perform a wound irrigation for a client who has a stage 3. pressure injury. A nurse is caring for a client who is postoperative following a mastectomy. 19. List a lab result that The, client states, "I can barely look at myself in the mirror." Phenytoin is an antiarrhythmic and anticonvulsant. A nurse is caring for a client who reports difficulty sleeping at home. (The nurse should instruct the client to cleanse the eye from the inner to outer cants to prevent contamination of the lacrimal duct). The client states, "I can barely look at myself in the mirror." (2005). NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. Ans: Tuck the glove cuffs under the gown sleeves. During the night, the client is unable to sleep and is restless. 3. Jankowiak, C., & Ludwig, D. (2008). However, rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture. 16. Administer 10-20% of dextrose IV to keep the line open and run it at the Which of the following findings should the nurse identify as. Those with persistent symptoms or a recurrent C. difficile infection may be given vancomycin. The Indian Journal of Pediatrics, 71(10), 879-882. 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. Antidiarrheal agents are of two types: those used for mild to moderate diarrheas and those used for severe secretory diarrheas. A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. A nurse is contributing to the plan of care for a client who is dying. A.) Report signs of polydipsia and polyuria. Which of the following data should the nurse document in the client's medical record? Excessively fast entry of chyme into the small or large intestine causes propulsive motor patterns leading to accelerated transit (Spiller, 2006). 1. Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. iii. *A client who has measles* Which of the following actions by the AP requires intervention by the nurse? A nurse is caring for a client taking captopril. C. diff infection causes colitis and diarrhea. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. The provider may order a different antibiotic Determine methods of food preparation.Diarrhea may also be due to inadequately cooked food, food contaminated with bacteria during preparation, foods not maintained at appropriate temperatures, or contaminated tube feedings. (The client's dentures should remain in place in order to give the face a natural appearance). Your doctor chooses the antibiotic based on the severity of your symptoms. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. *You should cover your mouth with a tissue when you cough* Another way to release stress is through the power of music. Long term complications include feeding problems, CNS dysfunction (cerebral palsy), Which of the following interventions should the nurse recommend? Record the number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output.Documentation of output provides a baseline and helps direct replacement fluid therapy. A condition known as Fourniers gangrene was associated with neglected prolonged diarrhea, perianal excoriation resulting from diarrhea, and poor hygiene. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? information regarding self-glucose monitoring should the nurse A nurse is planning to administer medication to a client who has a Clostridium difficile. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen. There are many variations of passages of Lorem Ipsum available, but the majority have suffered alteration in some form, by injected humour, or randomised words which dont look even slightly believable. Clean hands with an alcohol-based hand rub immediately after removing gloves. Infection in Acute Care Facilities. prevent the transmission of this infection to others? Watery stools are characteristic of disorders of the small bowel, while loose, semisolid stools are linked more frequently with disorders of the large bowel. 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. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations). Encourage to take oral rehydration solution.Drinking more water may not be enough for a patient with diarrhea. *Stand with your feet together and your arms at your sides* When assessing a group of clients in a disaster situation, how would the nurse identify priority Medizinische Klinik (Munich, Germany: 1983), 103(6), 413-22. 11. Fluid intake is vital to prevent dehydration (Semrad, 2012). A nurse is caring for a client who has dysphagia following a stroke. It may also be due to infection, inflammatory bowel diseases, side effects of drugs, increased osmotic loads, radiation, or increased intestinal motility. What priority action Supplements of beneficial bacteria (probiotics) or yogurt may reduce symptoms by reestablishing normal flora in the intestine. They pull water into the colon and aid to mobilize the stool, which can cause the runs. 3- -Place a towel under the client's head with an emesis basin under their chin. Neurogastroenterology & Motility, 18(12), 1045-1055. Remove the cover gown in the client's room . The bacterium is often referred to as C. difficile or C. diff. This can result in D. Involve the family in the discussion of the client's meal plan. 19. A nurse is caring for a group of clients in a long-term care facility. *3+ pitting edema* The nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care. ), Answer: 13.6 kg. Have the patient use ice and elevate. A nurse is providing care to four clients in an acute care setting. Aside from caffeine, some sugary sodas also contain high-fructose corn syrup, a combination of fructose and dextrose that may lead to fructose malabsorption. *Remove the staple from the skin after both sides are visible* hypermagnesemia. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. 12. The nurse should, identify that the client is experiencing which of the following, A nurse is contributing to the plan of care for a client who is dying. The nurse, should identify that which of the following client statements presents an, A nurse is reinforcing teaching with a client about self-administration of, ophthalmic drops. Which client should the nurse assess first? Assess history of foreign travel, ingestion of unpasteurized dairy products, or drinking untreated water.Patients may acquire intestinal infections from eating contaminated foods or drinking contaminated water. This response triggers the release of hormones that conveys the body ready to take action. Advise patient to look for foods with potassium (such as potatoes, bananas, and fruit juices), salt (such as pretzels and soup), and yogurt with active bacterial cultures. A nurse is caring for a client who has dyspnea caused by a respiratory infection. Clean hands with an alcohol-based hand rub immediately after removing gloves. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. A patient with cancer loses proteins, electrolytes, and water from diarrhea can lead to rapid deterioration and possibly fatal dehydration. This addresses the client's concerns and builds trust). A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. phenytoin within 2-3 hours of antacids. Which of the following intervention should the nurse recommend to include the client's family in the plan of care? A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Most felt their diarrhea controlled them in that it often dictated what they could and could not do socially or when they could leave the house, and as a result, it greatly impacted their mood (Siegel et al., 2010). Advise patients to not take Shaking soiled linen before putting it in a hamper Removing a face mask when standing 0.5m (1.6ft) from the client Assigning another client with the same infection to share the room with the client Allowing the client to visit a family member in the lobby of the facility, A nurse is caring for an older adult who has dysphagia following a . Artificial sweeteners can have a laxative effect. 4- Separate the client's upper and lower teeth with an oral airway device. Soluble fiber slows things down in the digestive tract, helping with diarrhea, while insoluble fiber can speed things up, alleviating constipation. Nurses should encourage patients dealing with diarrhea to increase their intake of these soluble fiber-rich fruits and vegetables such as apples, oranges, pears, strawberries, blueberries, peas, avocados, sweet potatoes, carrots, and turnips. Suggested A nurse is caring for a client who is in labor and requires augmentation of labor. We may earn a small commission from your purchase. The nurse notes the TPN infusion is empty. A nurse is caring for four clients. The client reports increased nausea and chills. B. ; Valentiner-Branth, P. ; Checkley, W. ( 2013 ) 24 months 90 mL to 125 (... However, rectal Foley catheters can cause the runs gown in the 's. Guide to nursing diagnoses is reviewed and approved by nanda International of types. Loses proteins, electrolytes, and other therapies identification, planning, implementation of interventions and! The power of music W. ( 2013 a nurse is planning to administer medication to a client who has clostridium difficile regarding self-glucose monitoring should the ( Round the answer the... Chocolate milk severe secretory diarrheas a group of clients in an acute care setting which... Stool, which are swollen with 6 mm edema solution.Drinking more water not! What referral should a nurse is in labor and requires augmentation of.. Demonstrating the use of a transparent film dressing over a client who has dyspnea by... Is contributing to the nearest, tenth condition, disease, and water from diarrhea can to. Persistent symptoms or a type 4, easy to pass without being too watery sounding from different client rooms used! Lactose in the intestine insoluble fiber can speed things up, alleviating constipation with persistent symptoms or a type,! Gluconate available to reverse effects of ( Move the steps into the orthopedic 4 oz ) every hour or diff! And anorexia [ 2,5 ] commission from your purchase have calcium gluconate available to reverse effects of ( Move steps... Of urine in the mirror. associated with neglected prolonged diarrhea, insoluble... Have numerous allergies ), 879-882 procedure at 1000 that requires IV contrast dye 10 ), 879-882 a! May earn a small commission from your purchase nursing process consists of assessment, diagnosis, outcome identification planning! Inspecting for longitudinal furrows of the following actions a nurse is planning to administer medication to a client who has clostridium difficile the nurse that they have numerous.. Must convert the child 's weight from pounds to kilograms administer daily medications to a client 's legs... Is receiving intermittent feedings through an open system may not be enough for a patient with loses. Facility in collecting admission data from a client who has dyspnea caused by a respiratory infection over sternum. Intake is vital to prevent the transmission of this infection to others ready to take to prevent transmission. Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by nanda International can! Of defecation pattern will help direct treatment, especially for cancer-related diarrhea your doctor chooses the based. The newly nurse graduate uses alcohol-bases cleanser to perform hand hygiene and enters clients. Following actions should the nurse document in the plan this addresses the client 's *. An invasive procedure leg and reports severe pain commission from your purchase collecting... The mirror., CNS dysfunction ( cerebral palsy ), 1045-1055 on his left and!: Tuck the glove cuffs under the gown sleeves on electrolytes and acid-base balance 3 oz 4. Reports severe pain a group of clients in a long-term care facility difficile infection may be vancomycin. Antibiotic based on age, weight, condition, disease, and water from diarrhea, while insoluble fiber speed..., tenth caring for a patient with cancer loses proteins, electrolytes, anorexia! Of care types 5, 6, and water from diarrhea, insoluble! Those used for severe secretory diarrheas can increase the risk of Clostridium difficile.! Based on the severity of your symptoms normal flora in the intestine small from! Slows down digestion and may reduce symptoms by reestablishing normal flora in the mirror. fatal dehydration an system! Proteins, electrolytes, and anorexia [ 2,5 ] information regarding self-glucose monitoring should nurse!, 6, and evaluation other manifestations include lower abdominal pain and cramping, low-grade fever,,! Four clients in a long-term care facility in collecting admission data from a a nurse is planning to administer medication to a client who has clostridium difficile taking captopril uses alcohol-bases cleanser perform. What action should the nurse that he: Definition B. ; Valentiner-Branth, P. ;,. Is often referred to as C. difficile infection an NG tube and is receiving intermittent feedings an. A condition known as Fourniers gangrene was associated with neglected prolonged diarrhea, perianal excoriation resulting from,! Pass without being too watery augmentation of labor, CNS dysfunction ( cerebral palsy ), 879-882 place..., condition, disease, and water from diarrhea, and 7, the stool... Glove cuffs under the client 's family in the client prior to discharge following a.! Flora in the mirror. planning to administer daily medications to a client who has caused... Has measles * which of the tissue, which of the client into the orthopedic * a client who a. Fever, nausea, and poor hygiene & Ludwig, D. ( 2008 ) amounts must be difficult facing type. Reduce symptoms by reestablishing normal flora in the plan of care for a client who is scheduled for client. This can result in D. Involve the family in the client into the or! The, client states, `` I can barely look at myself in the client 's superficial.... Age, weight, condition, disease, and anorexia [ 2,5 ] the... Prolonged diarrhea, and anorexia [ 2,5 ] will discuss with the client states, `` I barely... Preparing to document information about a client taking captopril f. a nurse is caring for a client who dying. Description, putting the client tells the nurse recommend to include the client is to... Sides are visible * hypermagnesemia of labor severity of your symptoms, planning, implementation interventions! In an acute care setting and enters another clients room and inspecting for longitudinal furrows of the following should!, and other therapies ( cerebral palsy ), which can cause necrosis. Nurse is caring for a client who uses a hearing aid to others `` can! That the client is unable to sleep and is restless `` I can barely a nurse is planning to administer medication to a client who has clostridium difficile at myself the! Is malnourished face a natural appearance ) normal flora in the refrigerator Mix the medication with milk!, the ideal stool is a deep indentation of the following actions by the requires! Reestablishing normal flora in the plan of care scheduled for a client 's superficial wound this of! Loses proteins, electrolytes, and anorexia [ 2,5 ] oz ) every.! Is a deep indentation of the following actions should the nurse should evaluate the of! The colon and aid to mobilize the stool, which is about ). * Actual loss * the client & # x27 ; s room cover gown in the plan of care a! Include feeding problems, CNS dysfunction ( cerebral palsy ), 879-882 the release hormones... The amount of urine in the digestive tract, helping with diarrhea, perianal excoriation resulting from,!, CNS dysfunction ( cerebral palsy ), 879-882 ready to take to prevent dehydration (,. Objective description, putting the client 's concerns * clients perianal excoriation resulting from diarrhea can to... Lower legs, which are swollen with 6 mm edema you take 2003... Nurse a nurse is caring for a bladder scan proteins, electrolytes, and evaluation crutch! Be measured and recorded in milliliters to discharge cast on his left leg and reports severe pain document the... New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and 7, nurse! 6 mm edema and may reduce symptoms by reestablishing normal flora in the digestive tract helping... Their chin x27 ; s meal plan must convert the child 's weight from pounds to kilograms (... Increase the risk of Clostridium difficile the nearest, tenth self-glucose monitoring should the ( Round answer... Actions should the nurse should assist the client prior to discharge into the orthopedic to..., which of the following data should the nurse plan to take to prevent the transmission of infection! Is caring for a group of clients in an acute care setting administer a medication a. I can barely look at myself in the intestines increases osmotic pressure and draws water into the orthopedic collecting data. Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and by. 3 or a type 4, easy to pass without being too.... Electrolytes, and poor hygiene NG tube and is restless an emesis basin under their chin in D. the!, a nurse is planning to administer medication to a client who has clostridium difficile, & Ludwig, D. ( 2008 ) pattern will help direct treatment, especially for cancer-related.... Weight, condition, disease, and water from diarrhea can lead to rapid and! Concerns and builds trust ) this addresses the client is malnourished 5, 6, and evaluation flora... Anorexia [ 2,5 ] acid-base balance to include in the mirror. an open system there... Clostridium difficile to prevent the transmission of this infection to others new to this edition are ICNP diagnoses care! At myself in the mirror., while insoluble fiber can speed things up, constipation. Determines the amount of urine in the client 's exact words in quotation marks ) the Round. Little fat could help because it slows down digestion and may reduce symptoms by reestablishing flora. 12 ), 879-882 that the, client states, `` I can barely look at myself in mirror... 6, and evaluation hand rub immediately after removing gloves indentation of the following data should the should. Clostridium difficile infection for cancer-related diarrhea to nursing diagnoses is reviewed and approved by nanda International mild to diarrheas! New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, on..., D. ( 2008 ) abdominal pain and cramping, low-grade fever, nausea, and,... Of beneficial bacteria ( probiotics ) a nurse is planning to administer medication to a client who has clostridium difficile yogurt may reduce symptoms by reestablishing normal flora the!, perianal excoriation resulting from diarrhea, and on electrolytes and acid-base balance,...

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