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 A

No explanation

A. Risk for infection. B. Impaired physical mobility. C. Risk for impaired skin integrity. D. Self care deficit.

Correct Answer is C

Explanation

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

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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

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is A

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is C

Explanation

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