A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Encourage the use of incontinence briefs.

Assist to a bedside commode 30 minutes after meals.

Administer a glycerin suppository 15 minutes after meals.

Insert a rectal tube at specified intervals.

Answer and Explanation

The Correct Answer is B

A. Encourage the use of incontinence briefs:

While incontinence briefs may help contain fecal leakage and protect clothing and bedding, they do not address the underlying issue of fecal incontinence or assist the client in achieving continence. Additionally, relying solely on incontinence briefs may not promote independence or improve the client's quality of life.

B. Assist to a bedside commode 30 minutes after meals:

This is the most appropriate intervention for establishing a bowel training regimen. Timing the use of the bedside commode after meals takes advantage of the gastrocolic reflex, which increases bowel motility after eating. Assisting the client to the commode at specific intervals helps promote regular bowel movements and may decrease the likelihood of fecal incontinence episodes.

C. Administer a glycerin suppository 15 minutes after meals:

While glycerin suppositories can stimulate bowel movements, they are typically used for acute constipation rather than chronic fecal incontinence. Additionally, using suppositories does not address the client's emotional distress or help establish a bowel training regimen focused on promoting continence.

D. Insert a rectal tube at specified intervals:

Rectal tubes are not typically used as a first-line intervention for bowel training in clients with fecal incontinence. They may be indicated in certain situations, such as severe impaction or when other interventions have failed, but they are not appropriate for all clients and may cause discomfort and complications.

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Correct Answer is C

Explanation

A. Provide a numeric pain scale:

While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.

B. Observe body language and movement:

Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.

C. Ask the client to describe the pain:

This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.

D. Identify effective pain relief measures:

Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.

A. Capillary refill of 2 seconds in the lower right foot. B. Basilar lung sounds that are diminished in the left lung. C. Contraction of the left pupil when light shines in the right eye. D. Active bowel sounds in the lower right quadrant.

Correct Answer is B

Explanation

A. Capillary refill of 2 seconds in the lower right foot:

Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.

B. Basilar lung sounds that are diminished in the left lung:

Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.

C. Contraction of the left pupil when light shines in the right eye:

Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.

D. Active bowel sounds in the lower right quadrant:

Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.

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A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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