N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

33. The greatest risk for injury for a client who has fecal incontinenceis: a. Perineal and rectal skinbreakdown b. The contamination of existingwounds c. Falls resulting from attempts to reach thebathroom d. Cross-contamination into the upper gastrointestinaltract 34. The nurse is providing ancillary personnel with instructions regarding theproper methods to implement when caring for a client with a Clostridium difficile infection. Which of the following practices will have the greatest impact on containment of the bacteria and thus prevention of cross-contamination? a. Frequent in-services on transmission modes of C. difficile b. Practice of proper hand hygiene by all staff c. Appropriate handling of contaminated linen d. Stool cultures on all suspected carriers 35. Which of the following clients is at greatest risk for serious complications when using the Valsalva maneuver to expel feces? a. 25-year-old pregnant client b. 66-year-old male with hypertrophied prostate c. 44-year-old male client with glaucoma d. 53-year-old female with stomach caner 36. The mother of an 18-month-old male client shares with the nurse that she is trying to get her child to tell her when he needs to have a bowel movement. Which of the following statements is the most appropriate response from the nurse? a. "I’m sure that you will be glad to have your son out of diapers." b. "I once heard of a child who was totally potty-trained by the time he was a year old." c. "Development of neuromuscular control of the bowels doesn’t normally occur until a child is between 2 and 3 year of age." d. "You will have to really be persistent about taking him to the bathroom frequently in order to be successful."

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