A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Limit the client's physical activity until bowel continence is achieved.
Limit the client's fluid intake to 1500 mL/day.
Instruct the client to limit their intake of high-fiber foods.
Assist the client to the restroom 30 minutes after meals.
The Correct Answer is D
Choice A Reason:
Limiting the client's physical activity is not generally recommended as part of bowel training for fecal incontinence. Regular physical activity can actually help with bowel movements by increasing muscle activity in the intestines. It is important for clients to maintain as much normal activity as possible.
Choice B Reason:
Limiting the client's fluid intake to 1500 mL/day is not advisable unless specifically recommended by a healthcare provider for another medical reason. Adequate hydration is essential for normal bowel function, and restricting fluids could exacerbate constipation, which can complicate fecal incontinence.
Choice C Reason:
Instructing the client to limit their intake of high-fiber foods would be counterproductive in managing fecal incontinence. A diet high in fiber can help form bulkier, softer stools, which can be easier to control. Fiber helps to regulate bowel movements, which is beneficial in bowel training programs.
Choice D Reason:
Assisting the client to the restroom 30 minutes after meals takes advantage of the gastrocolic reflex, which is a normal response where the act of eating stimulates movement in the gastrointestinal tract. This can help the client establish a regular pattern of bowel movements, which is a key goal in bowel training for fecal incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
Before administering any medication, it is crucial to verify the client's allergies to prevent adverse reactions. This step is paramount as it ensures patient safety and is a standard practice in medication administration protocols.
Choice B Reason:
Locating the correct injection site is essential for the efficacy of the drug and to minimize discomfort or complications. The area 5 cm to the right or left of the umbilicus is chosen because it is typically well-padded and has a lower risk of hitting bone or major blood vessels.
Choice C Reason:
The presence of an air bubble in the prefilled enoxaparin syringe is necessary to ensure the full dose is administered. Enoxaparin is an anticoagulant medication, and the air bubble does not pose a risk when injected subcutaneously but helps to clear the syringe of medication.
Choice D Reason:
The technique of pinching the skin and inserting the needle at a 90-degree angle is used to create a skinfold for subcutaneous injections. This method helps to ensure that the medication is delivered into the subcutaneous tissue rather than into muscle or dermis.
Choice E Reason:
Injecting the medication slowly and without aspirating is specific to subcutaneous injections like enoxaparin. Aspiration is not recommended for subcutaneous injections as it can cause tissue damage and is unnecessary since large blood vessels are not present at the recommended injection sites.
Correct Answer is A
Explanation
Choice A Reason:
For a client with AIDS and malnutrition, providing a high-calorie diet is essential. Malnutrition can be a significant issue for individuals with AIDS due to various factors, including decreased appetite, nutrient malabsorption, and the increased metabolic demands of the body fighting the infection. A high-calorie diet can help meet the increased energy requirements and improve nutritional status, which is crucial for maintaining immune function and overall health.
Choice B Reason:
Encouraging three large meals daily may not be the best approach for someone with AIDS and malnutrition. Large meals can be overwhelming and may lead to decreased overall intake if the client feels too full or has a poor appetite. Instead, frequent small meals and snacks throughout the day can be more manageable and effective in meeting the client's nutritional needs.
Choice C Reason:
Administering an antiemetic after each meal may be necessary if the client experiences nausea, which can be a side effect of medications or the illness itself. However, this should be based on the client's symptoms and needs, rather than a routine practice. Antiemetics can help manage nausea and improve food intake, but they should be used judiciously and as needed.
Choice D Reason:
Seasoning foods with spices can enhance flavor and may improve food intake for some clients. However, this should be tailored to the individual's taste preferences and tolerance. Some individuals with AIDS may have altered taste sensations or may be sensitive to certain spices, so it's important to consider these factors when seasoning foods.
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