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A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

A.

Limit activity.

B.

Drink four to five glasses of water daily.

C.

Increase dietary intake of raw vegetables.

D.

Bear down hard when defecating.

Answer and Explanation

The Correct Answer is C

Rationale: 

 

A. Limiting activity can contribute to constipation, so the nurse should encourage regular physical activity to promote bowel function. 

 

B. Drinking four to five glasses of water daily is insufficient; older adults typically need at least 6-8 glasses to help prevent constipation. 

 

C. Increasing dietary intake of raw vegetables provides fiber, which is essential for promoting bowel regularity and preventing constipation. This recommendation aligns with dietary guidelines for improving gastrointestinal health. 

 

D. Bearing down hard when defecating can lead to complications such as hemorrhoids or valsalva maneuvers, so clients should be taught to relax and allow for a natural bowel movement instead.

 


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Correct Answer is A

Explanation

Rationale:

A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.

B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.

C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.

D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.

Correct Answer is B

Explanation

Rationale:

A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.

B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.

C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.

D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.

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