A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?
Stop the enema and document that the client did not tolerate the procedure.
Allow the client to expel some fluid before continuing.
Encourage the client to bear down.
Lower the height of the solution container.
The Correct Answer is D
A. Stop the enema and document that the client did not tolerate the procedure: This action might be necessary in some cases, but it’s not the first action to take. The nurse should first try to alleviate the client’s discomfort.
B. Allow the client to expel some fluid before continuing: This action could potentially relieve some discomfort, but it’s not the most effective initial response. The cramping is likely due to the speed at which the fluid is entering, not the amount of fluid already administered.
C. Encourage the client to bear down: This action is not typically recommended during an enema administration as it could increase discomfort.
D. Lower the height of the solution container: This is the correct action. Lowering the height of the solution container will decrease the speed at which the fluid is entering the client’s rectum, which can help alleviate cramping and discomfort. Therefore, option D is the most appropriate action for the nurse to take.
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Correct Answer is D
Explanation
A. Muscular dystrophy: This is a group of diseases that cause progressive weakness and loss of muscle mass. It’s not a neural tube defect.
B. Cerebral palsy: This is a group of disorders that affect a person’s ability to move and maintain balance and posture. It’s not a neural tube defect.
C. Hydrocephalus: This is a condition that occurs when fluid builds up in the skull and causes the brain to swell. It’s not a neural tube defect, but it can occur as a complication of spina bifida.
D. Spina bifida: This is the correct answer. Spina bifida is a neural tube defect that occurs when the spine and spinal cord don’t form properly. This is a condition that is present at birth (congenital).
Correct Answer is C
Explanation
A. Droplet: Measles is not primarily spread through large respiratory droplets that are expelled when a person coughs or sneezes. These droplets do not remain in the air and generally only travel a short distance.
B. Contact: While measles can be spread through direct contact with an infected person, it is not the primary mode of transmission.
C. Airborne: This is the correct answer. Measles is a highly contagious disease that is spread through the air by respiratory droplets. It can remain in the air for up to two hours after an infected person leaves an area.
D. Protective environment: This type of isolation is typically used for individuals who have weakened immune systems and are at high risk of infection, not for those with measles.
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