A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?
Limit activity.
Drink four to five glasses of water daily.
Increase dietary intake of raw vegetables.
Bear down hard when defecating.
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. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.
B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.
C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.
D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.
Correct Answer is B
Explanation
Rationale:
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.