A nurse is caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal quadrants. Which of the following actions should the nurse perform?

Choice A Reason:

Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.

Choice B Reason:

Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.

Choice C Reason:

Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.

Choice D Reason:

Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.

Choice A Reason:

Glatiramer acetate is incorrect because it is used in the treatment of multiple sclerosis (MS) to reduce the frequency of relapses and delay disease progression. It is not indicated for spasm-induced incontinence.

Choice B Reason:

Dulaglutide is incorrect because it is a medication used to treat type 2 diabetes by improving blood sugar control. It is not indicated for the treatment of spasm-induced incontinence.

Choice C Reason:

Montelukast sodium is incorrect because it is a leukotriene receptor antagonist primarily used to manage asthma and allergic rhinitis. It is not indicated for the treatment of spasm-induced incontinence.

Choice D Reason:

Oxybutynin is an anticholinergic medication commonly used to treat overactive bladder and urinary incontinence, including spasm-induced incontinence that can occur in individuals with spinal cord injury. It works by relaxing the smooth muscles of the bladder, thereby reducing involuntary contractions that contribute to urinary urgency and incontinence.