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 C
Explanation
Choice A reason:
Taking several antituberculosis medications does not primarily aim to protect the liver from toxic effects. While liver protection is a concern during TB treatment due to the hepatotoxicity of some TB medications, the primary reason for multiple drugs is not liver protection.
Choice B reason:
Some pain is expected after fracture and cast application. However, if the pain is severe, unrelieved by prescribed analgesics, or increases over time, it may indicate complications such as compartment syndrome. In such cases, prompt evaluation is necessary.
Choice C reason:
When a client has a long arm cast applied, it's crucial to monitor for signs of circulatory compromise, such as coolness in the fingers. Cool fingers may indicate inadequate blood flow, potentially leading to serious complications like compartment syndrome. Immediate reporting to the healthcare provider is necessary to prevent further complications.
Choice D reason:
The severity of TB does not determine the number of medications required. Both severe and less severe forms of TB typically require a combination of medications to effectively treat the disease and prevent the development of drug-resistant TB strains.
Correct Answer is C
Explanation
Choice A reason:
Diaphoresis, or excessive sweating, can be a symptom of hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar). In the context of diabetes, diaphoresis often occurs when the blood sugar levels drop too low, as the body releases adrenaline in response to the hypoglycemia, which stimulates sweating. Normal blood sugar levels range from 70 to 100 milligrams per deciliter (mg/dL) while fasting.
Choice B reason:
The absence of urinary ketones does not necessarily indicate hyperglycemia. Ketones in the urine are typically a sign of ketoacidosis, which can occur in the context of both high and low insulin levels. In hyperglycemia, if insulin is present but not sufficient, the body may not produce ketones. However, if insulin is absent or extremely low, as in diabetic ketoacidosis, ketones will be present due to the breakdown of fats for energy.
Choice C reason:
Kussmaul respirations are deep, labored breathings often associated with severe hyperglycemia, particularly when it has progressed to ketoacidosis. This type of respiration is the body's response to acidosis, as it attempts to expel excess carbon dioxide to compensate for the metabolic acidosis caused by the accumulation of ketones. Kussmaul respirations are a classic sign of diabetic ketoacidosis, which is a serious complication of uncontrolled diabetes.
Choice D reason:
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels in the blood), not hyperglycemia. It is elicited by tapping on the facial nerve and observing for twitching of the facial muscles, which indicates neuromuscular excitability due to low calcium. It is not related to blood sugar levels.
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