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 D
Explanation
Choice A Reason:
Activating the fire alarm system is an important step in the event of a fire, as it alerts other staff and triggers emergency protocols. However, the immediate priority is the safety of the client. The nurse should ensure that the client is out of harm's way before activating the alarm.
Choice B Reason:
Using a fire extinguisher at the source of the smoke may be necessary if the fire is small and contained, and if the nurse is trained to do so. However, this action should only be taken after ensuring the client's safety and if it does not pose a risk to the nurse or the client.
Choice C Reason:
Closing the doors to the room and to the bathroom can help contain the smoke and prevent the spread of fire. This is a critical step, but it is not the first action the nurse should take. The nurse's first responsibility is to the safety and well-being of the client.
Choice D Reason:
The first action the nurse should take is to assist the client to a nearby common area, away from the source of the smoke. This aligns with the RACE acronym (Rescue, Alarm, Contain, Extinguish) used in fire safety, which prioritizes removing anyone in immediate danger.
Correct Answer is A
Explanation
Choice A reason:
Applying a cooling blanket is a critical intervention for a patient with malignant hyperthermia, a life-threatening condition characterized by a rapid rise in body temperature and severe muscle contractions following exposure to certain anesthetic agents. The cooling blanket helps to reduce the patient's body temperature, which can prevent further complications associated with hyperthermia.
Choice B reason:
Instilling a warm enema solution is not an appropriate action for malignant hyperthermia. This condition requires measures to reduce body temperature, not increase it. A warm enema could potentially worsen the hyperthermic state.
Choice C reason:
Administering meperidine (an opioid analgesic) intramuscularly is not recommended in the management of malignant hyperthermia. Meperidine does not play a role in the treatment of this condition and could complicate the clinical picture due to its pharmacological effects.
Choice D reason:
Ventilating the client with 50% oxygen is part of the supportive care for malignant hyperthermia, but it is not the primary intervention. The main goal is to treat the hypermetabolic state and reduce body temperature. While oxygenation is important, it should be accompanied by other specific treatments for malignant hyperthermia, such as administering dantrolene and active cooling measures.
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