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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:
Using moisturizing soap to clean around the stoma is not recommended. Moisturizers can leave a residue that interferes with the adhesive of the ostomy appliance, leading to poor seal and potential leakage. Instead, the area should be cleaned with mild soap and water, and thoroughly dried.

Choice B Reason:
Cutting the wafer opening one-fourth of an inch larger than the stoma is incorrect. The wafer should be cut to fit snugly around the stoma to prevent skin irritation and ensure a secure seal. A gap that is too large can allow output to contact the skin, which can cause irritation and breakdown.

Choice C Reason:
Using a skin sealant before applying the bag is a correct practice. A skin sealant can protect the skin around the stoma from irritation caused by the stoma output. It also helps to create a better seal between the skin and the ostomy appliance, which can prevent leakage.

Choice D Reason:
The frequency of emptying the ileostomy bag can vary based on individual output and the consistency of the stool. While it may be necessary to empty the bag every 4 to 6 hours, this statement alone does not indicate a full understanding of ileostomy care. It's important to empty the bag when it's one-third to one-half full to prevent leakage and maintain comfort.

A. Move the overbed table away from the bed. B. Leave the television on in the client's room. C. Apply a motion sensor mat to the client's bed. D. Raise all four side rails while the client is in bed.

Correct Answer is C

Explanation

Choice A reason:
Moving the overbed table away from the bed may reduce clutter and potential obstacles, which is generally a good practice in fall prevention. However, it does not directly address the immediate risk of the client falling out of bed. The overbed table, if positioned correctly, can also be used to hold personal items within easy reach of the client, reducing the need for them to stretch or reach out, which could potentially lead to a fall.

Choice B reason:
Leaving the television on in the client's room might provide a sense of comfort or distraction, but it does not contribute to fall prevention. In fact, the noise and light from the television could potentially disrupt the client's sleep pattern, leading to disorientation or restlessness, which can increase the risk of falls, especially in clients with dementia.

Choice C reason:
Applying a motion sensor mat to the client's bed is a proactive measure to prevent falls. If the client attempts to get out of bed, the sensor will trigger an alarm, alerting the nursing staff to assist the client. This intervention is particularly useful for clients with dementia who may not remember to call for assistance when getting up, thus reducing the risk of falls.

Choice D reason:
Raising all four side rails while the client is in bed may seem like a protective measure, but it can actually increase the risk of injury. Clients with dementia may become confused and attempt to climb over the rails, leading to a higher fall and potential injury. Moreover, the use of full side rails can be considered a form of restraint, which is generally discouraged in patient care unless absolutely necessary.

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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?

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