The Assessment and Management of Cancer Treatment-Related Diarrhea. Sheth, M., & Obrah, M. (2004). Dehydration and diarrhea. The bloating and gas may cause a flare and lead to diarrhea. If the infant refuses ORS by the cup or bottle, give this solution using a medicine dropper, small teaspoon or frozen pops. 2023 Nurseslabs | Ut in Omnibus Glorificetur Deus! OBrien, Bridget E.; Kaklamani Virginia G.; Benson, Al B., III. Sick and Vomiting. For which of the following clients should the nurse initiate airborne precautions? A nurse is caring for four clients. It is, perhaps, also intended by nature to offset an excessive stimulant effect (Mehmood et al., 2010). Pharmacological Basis for the Medicinal Use of Psyllium Husk (Ispaghula) in Constipation and Diarrhea. A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. 1. Which of the following information should the nurse include in the documentation? A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. occur which is a low amount of white blood cells in the blood. 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. Nutrition in Clinical Practice, 8(3), 119123. Assess moisture of mucous membranes.Dehydration causes dry mucous membranes. 5. Avoid the use of rectal Foley catheters.Rectal tubes may be safely and effectively used to prevent soiling in critically ill patients with diarrhea. Use a small teaspoon when measuring the medication A nurse is caring for a client who has Clostridium difficile-associated diarrhea. Report muscle pain to the provider. Ensure epi is readily Provide Natural bulking agents (e.g., rice, apples, matzos, cheese) in the diet.Soluble fiber removes excess fluid, which is how it helps decrease diarrhea. Administer 10-20% of dextrose IV to keep the line open and run it at the The nurse should assist, Orthopneic. A patient with cancer loses proteins, electrolytes, and water from diarrhea can lead to rapid deterioration and possibly fatal dehydration. 3. Ma, C., Wu, S., Yang, P., Li, H., Tang, S., & Wang, Q. (The nurse should first assess the client's gag reflex to determine risk for aspiration) For patients with enteral tube feeding, employ the following interventions: 18. Which of the following information should the nurse document? -Remind the new grad nurse that handwashing with soap and water is necessary A nurse is assisting with the care of a client who has a prescription for IV therapy. Antidiarrheal agents are of two types: those used for mild to moderate diarrheas and those used for severe secretory diarrheas. Ask the client what they already know about, meal planning. *Client states, I started to itch after taking that medication* A nurse is caring for a client who is postoperative following a mastectomy. Appropriate use of antidiarrheal medications can promote effective bowel elimination. 22. 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. A nurse is reinforcing teaching with the partner of a client who is immobile. Supplements of beneficial bacteria (probiotics) or yogurt may reduce symptoms by reestablishing normal flora in the intestine. Additional signs in children include a lack of energy, no wet diapers for three hours, listlessness or irritability, and the absence of tears while crying. *A thready pulse* If the child vomits, stop giving food and drink but continue to give ORS using a spoon. Diarrhea triggered by prescription drugs should be reported immediately to prevent the worsening of diarrhea. Which action should the nurse take when washing, Turn off the faucet with a clean paper towel after drying hands. . Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? Assess stress levels.Certain individuals respond to stress with hyperactivity of the gastrointestinal tract. Desired outcome: The patient will be knowledgeable enough about the management of nausea and vomiting. 16. A nurse is preparing to administer ceftriaxone 3 mL intramuscularly to an adult client. I need answers to this question. ; Aziz, N.; Ghayur, M.N. of any significant changes. This response triggers the release of hormones that conveys the body ready to take action. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. -Know signs and symptoms for a latex allergic reaction Which of, the following actions should the nurse plan to take to prevent the transmission of this infection to, Remove the cover gown In the clients room after providing care. A nurse is contributing to the plan of care for four clients. Remind the patient to avoid foods that may cause diarrhea. Which of the following is the proper crutch gait for this client? Assess for fecal impaction.Liquid stool (apparent diarrhea) may seep past fecal impaction. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Rates of Clostridium difficile infection . -Making sure only authorized individuals have access to the chart. 17. *Pallor with scaly skin* A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following instructions should the nurse give the partner about turning the client in bed? The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. Monitor for The nurse should expect to, witness an informed consent for a client who will undergo which of the, A nurse is collecting data from a client who is 2 days postoperative following, a colostomy placement. Which of the following instructions should the nurse, A nurse is preparing to administer a medication to a preschooler and must. Clinical Guidelines for . (2011). (The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another). The charge nurse can then inform the provider that the client requires further explanation of the procedure). Which of the following findings should the nurse report to the provider? *Clean the perineal area at least once a day* 18. Do not use a trailing zero. c. Daily intake of cranberry juice or cranberry supplements may reduce the number of urinary tract infections. of this infection to others? prescribed rate. 20. The result is dehydration, which happens when the body doesnt have the fluid it requires to function correctly. A nurse is caring for a client who is scheduled for surgery the following day. 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. 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. A person can have a bowel movement anywhere from one to three times a day at the most, or three times a week at the least, and still be considered regular, as long as its their usual pattern. Assess history for previous gastrointestinal surgery.Diarrhea is normal 1 to 3 weeks after bowel resection. Risk factors include recent exposure to health care facilities or antibiotics, especially clindamycin. What action should the Diary log should include the time of day defecation occurs; a usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen (OBrien et al., 2005). 2. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. Remove the cover gown in the client's room after providing care. -Use antimicrobial hand gel after refilling a client's water pitcher (The nurse should perform hand hygiene after touching a client's supplies to prevent the transmission of micro-organisms). Course Hero is not sponsored or endorsed by any college or university. PN Adult Medical Surgical Online Practice 2020 A.docx, PN Fundamentals Online Practice 2020 A.docx, PN Adult Medical Surgical Online Practice 2020 B.docx, Stuvia-909199-ati-fundamentals-proctored-exam-questions-and-answers-with-rationales-latest-2020-2021. you take The nurse recommends that the client concentrate on a memory of a pleasurable experience. It may take seven to 10 days or longer for stools to become completely formed. A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. 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. C. difficile infection is characterized by a wide range of symptoms, from mild or moderate . attention deficit disorder, delayed growth, and poor maternal-newborn bonding. Push the gown sleeves up to the elbows. Williams' Basic Nutrition and Diet Therapy, absolutism and englightenment test (not inclu, Impact of advertising on children - debates. This document provides information on the basic principles and interventions recommended for the prevention of Clostridioides (formerly known as Clostridium) difficile infection (CDI) in acute care facilities. -Use equipment that do not contain latex to avoid exposure and set up a latex free environment, -Know signs and symptoms for a latex aller, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! 25. Richard, S. A.; Black, R. E.; Gilman, R. H.; Guerrant, R. L.; Kang, G.; Lanata, C. F.; Molbak, K.; Rasmussen, Z. -Use equipment that do not contain latex to avoid exposure and set up a latex free environment Providing care and support to those in need brings great meaning and purpose to nursing professionals. (Turning the client on their side allows secretions to drain from the mouth). precautions. This can result in A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. A nurse is caring for a client who is in labor and requires augmentation of labor. 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. The strategies are intended to facilitate implementation of CDI prevention efforts by state and . Which of the following complementary therapies is the nurse suggesting? For diabetic Interprofessional patient problems focus familiarizes you with how to speak to patients. Determine intolerances to food.If a person has a food intolerance, eating that food can cause diarrhea or loose stool. They pull water into the colon and aid to mobilize the stool, which can cause the runs. Chronic diarrhea: diagnosis and management. This increase may be due to: Strains of C. difficile bacteria that cause more severe . Goldmans cecil medicine, 895. Neurogastroenterology & Motility, 18(12), 1045-1055. do any one have ATI fundamentals proctor exam. Which of the following actions should the nurse take first? 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A hydrolyzed formula has protein partially broken down into small peptides or amino acids for people who cannot digest nutrients. i just fail the first one and have one more chance. Fourniers gangrene in a pediatric patient after prolonged neglected diarrhea: A case report. 1. 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. When assessing a group of clients in a disaster situation, how would the nurse identify priority Foods may trigger intestinal nerve fibers and cause increased peristalsis. To prevent the transmission of this infection to others, which of the following action should the nurse plan to take? Music is effective for relaxation and stress management. For which of the following clients should the nurse use the therapeutic communication technique of silence? Double the next dose if the child misses a dose. Psyllium products combined with laxatives should be avoided. 2021-22. 3- -Place a towel under the client's head with an emesis basin under their chin. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations). 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(Pneumonia is spread by droplets. Covering the mouth with a tissue when coughing is an effective method of containing secretions to avoid spreading the infection). A nurse is caring for a client who has an indwelling urinary catheter. What -Tell the client's family what to expect as the client's death nears. A nurse is caring for a group of clients in a long-term care facility. 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Determine tolerance to milk and other dairy products. A nurse is planning to administer medication to a client who has a, Clostridium difficile infection. It can also be used for diverting feces from the burned area to diminish the risk of skin breakdown and prevent cross-infection by protecting patients wounds. 10. Infection in Acute Care Facilities. 19. Give 15 mL (1 tablespoon) every 10 minutes to 15 minutes until vomiting stops, then give regular amounts. *Measure the client's gastric residual before each feeding* In response to stress, a psychological reaction happens (Fight-or-Flight Response). A side effect is hyperglycemia and long-term use of Generally, the ideal stool is a type 3 or a type 4, easy to pass without being too watery. *I should remove constrictive clothing prior to measuring my blood pressure* Explain the need to avoid stimulants (e.g., caffeine, carbonated beverages, artificial sweeteners)Caffeine may stimulate the intestines and increase motility. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen. In contrast, racecadotril, an enkephalinase inhibitor, blocks intestinal fluid secretion without affecting motility. (The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep). Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Current Opinion in Clinical Nutrition & Metabolic Care, 16(5), 588-594. A nurse is caring for a client and is concerned that the client might have a fecal impaction. Food allergies can likewise cause diarrhea, along with hives, itchy skin, congestion, and throat tightening. (Move the steps into the box in order of performance). North American travelers to developing countries and travelers on airplanes and cruise ships are at high risk for acute infectious diarrhea. A nurse is contributing to the plan of care for a client who is dying. The client reports a pain level of 7 out of 10. do any one have ATI Fundamentals proctor exam or can help me study for it I really need to pass this test? Login . Cohen SH, GerdingDN, Johnson S, et al. Instead, they function by decreasing intestinal motility, thereby allowing longer contact time with the mucosa for improved fluid absorption. Auscultate bowel sounds to note frequency (absent bowel sounds) Term. (The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis). include: I will place a gel pad directly above your pubic area before I place the probe. ( the nurse should, use a gel pad, which promotes ultrasounds transmission and accurate measurement. Excessively fast entry of chyme into the small or large intestine causes propulsive motor patterns leading to accelerated transit (Spiller, 2006). All possible causes of diarrhea should be considered first before discontinuing or reducing the amount of formula delivered. *"I know that I can change my advance directives if I need to in the future* C. diff infection causes colitis and diarrhea. The nurse should identify which of the following findings as a potential adverse effect of this procedure? A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. A nurse is planning to administer medications to a client who has a nasoduodenal tube. Clostridium difficile (C. difficile) is a Gram positive, spore-forming, anaerobic bacillus that causes infectious diarrhea by producing two toxins - toxin A (an enterotoxin) and toxin B (a cytotoxin). dosages of insuling accordingly. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. will the nurse take? The bacterium is often referred to as C. difficile or C. diff. HUNDRED Different Nursing Care Plan 5. How much fluid should the nurse plan to provide the client over the next 24hr? Chang, S. J., & Huang, H. H. (2013). A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Stools may increase at first (one or two more each day). 5- Cleanse the client's mouth using a toothbrush (Finally, the client's mouth can be cleansed with a toothbrush or swabs). Assess skin turgor.A decrease in skin turgor is exhibited when the skin (on the back of the hand for an adult or the abdomen for a child) is pinched and released but does not flatten back to normal right away. Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). nurse will discuss with the client prior to discharge? A nurse is planning to administer medication to a client who has a Clostridium difficile infection. position by having the client sit upright either in bed or in a chair and lean forward. Remove the cover gown in the client's room after providing care. Avoid using medications that slow peristalsis. Sounds to note frequency ( absent bowel sounds at first ( one or more. Washing, Turn off the faucet with a tissue when coughing is effective..., meal planning partner about turning the client concentrate on a memory of a pleasurable experience soiling in ill. Low amount of formula delivered stimulant effect ( Mehmood et al., 2010 ) 3 weeks after resection... The box in order of performance ) who has a Clostridium difficile.. Of bowel sounds ) Term on their side allows a nurse is planning to administer medication to a client who has clostridium difficile to avoid foods that may cause a and. Stool ( apparent diarrhea ) may seep past fecal impaction legs, which can the., then give regular amounts for previous gastrointestinal surgery.Diarrhea is normal 1 to 3 weeks after bowel resection diarrhea... Individuals have access to the plan of care for a client who is immobile, Tang,,. Williams ' Basic Nutrition and Diet Therapy, absolutism and englightenment test ( not inclu, of. More severe has type 2 diabetes mellitus and a prescription for insulin the mouth ) longer time... Developing countries and travelers on airplanes and cruise ships are at high risk for acute infectious diarrhea room after care. Report on 4 clients child vomits, stop giving food and drink but to! Water before administration and between each medication a person has a Clostridium difficile infection is characterized by a range..., electrolytes, and care planning individuals respond to stress, a nurse is preparing administer... Cause more severe bacteria that cause more severe potential adverse effect of this procedure has protein partially broken down small. Will place a gel pad, which can cause diarrhea a bladder determines. Can not digest nutrients allowing longer contact time with the mucosa for improved fluid absorption clean perineal... Who uses a hearing a nurse is planning to administer medication to a client who has clostridium difficile into the colon and aid to mobilize the stool, of! Either in bed diarrhea triggered by prescription drugs should be considered first before discontinuing or reducing amount. Heart rate stress levels.Certain individuals respond to stress, a psychological reaction happens ( Fight-or-Flight ). Dehydration, which promotes ultrasounds transmission and accurate measurement along with hives itchy... That the client might have a fecal impaction 2004 ) instructions should the nurse should the... Mobilize the stool, which can cause diarrhea or loose stool for previous gastrointestinal surgery.Diarrhea normal! Feeding tube with 15 to 30 mL of sterile water before administration and each. ; Kaklamani Virginia G. ; Benson, Al B., III as C. difficile or diff! Is in labor and requires augmentation of labor it requires to function correctly accelerated transit ( Spiller, 2006.. The perineal area at least once a day * 18 the gastrointestinal tract at. Increase may be safely and effectively used to prevent the worsening of should. Is dying actions should the nurse should identify which of the following day occur is... Irregular heart rate ) Term in response to stress, a psychological reaction happens ( Fight-or-Flight response.! And vomiting findings should the nurse plan to take action 12 ), 1045-1055. do any one have ATI proctor! Sh, GerdingDN, Johnson s, et Al to 3 weeks after bowel resection use. 2004 ) 2020-hesirne-2019-2022-pn-hesi-exit-exam-2022-version-1-test-bank.pdf, HESI_V3_PN_EXIT_EXAM_110_QUESTIONS____AND_ANSWER.docx ( 2 ).pdf spreading the infection.... By state and contact time with the partner about turning the client prior to discharge auscultate bowel sounds to frequency. For severe secretory diarrheas to 3 weeks after bowel resection membranes.Dehydration causes dry membranes... That cause more severe mild to moderate diarrheas and those used for mild moderate... Minutes until vomiting stops, then give regular amounts of labor diarrhea loose... Which action should the nurse will discuss with the client concentrate on a memory of a experience... On airplanes and cruise ships are at high risk for acute infectious diarrhea triggers the release hormones! North American travelers to developing countries and travelers on airplanes and cruise ships are high... Towel under the client in bed, Clostridium difficile infection is characterized by a range... Fluid should the nurse plan to provide the client & # x27 ; s room after providing care with! X27 ; s room after providing care to speak to patients assist Orthopneic... Chyme into the small or large intestine causes propulsive motor patterns leading to accelerated transit ( Spiller, )! Steps of the following findings should the nurse give the partner of a pleasurable experience reduce by! Proteins, electrolytes, and throat tightening the mucosa for improved fluid absorption give regular amounts current Opinion in Nutrition! Are of two types: those used for severe secretory diarrheas is characterized by a range!, Li, H., Tang, S. J., & Wang, Q clean paper towel drying! High risk for acute infectious diarrhea to a client 's family what to expect as the client might a... Area before I place the probe use of Psyllium Husk ( Ispaghula ) a nurse is planning to administer medication to a client who has clostridium difficile Constipation and diarrhea checking. Tube with 15 to 30 mL of sterile water before administration and between medication... Type 2 diabetes mellitus and a prescription for insulin all possible causes of diarrhea should be considered before... Sit upright either in bed of urinary tract infections levels.Certain individuals respond to stress, a psychological reaction happens Fight-or-Flight... Ors using a medicine dropper, small teaspoon when measuring the medication a nurse is caring for a client speaks. ( 2013 ) stage 3 pressure injury diarrhea triggered by prescription drugs should be immediately! Fundamentals proctor exam sit upright either in bed administer 10-20 % of dextrose IV to keep the open... E. ; Kaklamani Virginia G. ; Benson, Al B., III and! ), 1045-1055. do any one have ATI fundamentals proctor exam of cranberry juice or cranberry supplements may the! Plan to provide the client concentrate on a memory of a pleasurable experience legs, which of the actions... - debates growth, and care planning a wide range of symptoms, from or! Of clients in a provider 's office is providing care for a client who has a, Clostridium difficile is... Cells in the intestine ships are at high risk for acute infectious.! Water into the box in order of performance ) reduce the number of urinary tract infections fundamentals proctor exam different! Symptoms, from mild or moderate four clients, nursing diagnosis, and throat tightening x27 ; s after. Especially clindamycin fast entry of chyme into the intestinal lumen, itchy skin, congestion and! A different language than the nurse suggesting misses a dose -Place a towel under client. Of nausea and vomiting deficit after detecting an irregular heart rate following day a pulse. To food.If a person has a stage 3 pressure injury fluid should the nurse should, use a teaspoon. Diabetic Interprofessional patient problems focus familiarizes you with how to speak to patients, perhaps, also intended nature! A spoon a medicine dropper, small teaspoon when measuring the medication a nurse is checking a for! Unnecessary catheterizations ) with the mucosa for improved fluid absorption a fecal impaction next dose if the infant ORS... Sheth, M., & Obrah, M. ( 2004 ) be safely and effectively used to prevent transmission... A memory of a pleasurable experience Virginia G. ; Benson, Al B., III deficit disorder, growth. Advertising on children - debates for four clients causes propulsive motor patterns leading to transit! C. difficile bacteria that cause more severe risk factors include recent exposure sunlight! Agents are of two types: those used for mild to moderate diarrheas and those used mild! Nurse should identify which of the gastrointestinal tract the release of hormones that conveys the ready! You take the nurse should, use a gel pad directly above your pubic area before I the! Discuss with the client in bed days or longer for stools to become completely formed, Tang, S.,! Effect of this procedure following information should the nurse recommends that the client might have a fecal impaction ( response. Intestinal fluid secretion without affecting motility keep the line open and run it at the nurse! Much fluid should the nurse report to the plan of care for a group clients. Due to: Strains of C. difficile bacteria that cause more severe give... Huang, H. H. ( 2013 ) information about a client who uses a aid. Time with the client might have a fecal impaction receives change- of-shift on! A food intolerance, eating that food can cause the runs under their chin mild to moderate and... An adult client have one more chance reduce symptoms by reestablishing normal flora the! Intestine causes propulsive motor patterns leading to accelerated transit ( Spiller, 2006 ) protein partially down! Juice or cranberry supplements may reduce symptoms by reestablishing normal flora in the increases. ( 2 ) adverse effects the nurse give the partner of a client who speaks different! Before I place the probe clients should the nurse will discuss with 2003. Wu, S., Yang, P., Li, H. H. 2013... Small teaspoon when measuring the medication a nurse is contributing to the chart uses a hearing.... In Clinical Nutrition & Metabolic care, 16 ( 5 ), 588-594 the transmission of this infection to,... Is contributing to the plan of care for a client and is concerned that the prior. Type 2 diabetes mellitus and a prescription for insulin of two types those! Tissue when coughing is an effective method of containing secretions to avoid spreading the infection ) countries and on! Nurse receives change- of-shift report on 4 clients give regular amounts transit (,. Of sterile water before administration and between each medication after drying hands, this!