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 D

Explanation

A. Places food on the unaffected side of the mouth:

This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.

B. Raises the head of the bed to 60 degrees:

This is appropriate as it helps reduce the risk of aspiration by promoting proper positioning during feeding.

C. Positions the head with the chin tilted slightly downward:

Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.

D. Allows 30 minutes of rest before feeding:

This is incorrect because it’s generally important to avoid long periods of rest before feeding. The client should be well-rested, but allowing 30 minutes specifically as a rest period before feeding is not a standard practice and may not align with the client's needs or feeding protocols.

A. Encourage Increased fluid intake and measure urinary output every 8 hours. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Provide comfort measures such as topical warm application and tactile massage. E. Implement a 24 hour schedule of routine administration of prescribed analgesic.

Correct Answer is ["B","C","D","E"]

Explanation

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

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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 observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is D

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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