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 A

Explanation

Choice A reason:
Checking the client for ecchymosis is an important part of care for patients with thrombocytopenia. Ecchymosis, or bruising, can be a sign of bleeding under the skin and may indicate a drop in platelet count. Since normal platelet counts range from 150,000 to 450,000 platelets per microliter of blood, and thrombocytopenia involves counts lower than this, monitoring for signs of bleeding is crucial.

Choice B reason:
Administering ibuprofen for a mild headache is not recommended for clients with thrombocytopenia. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can inhibit platelet function and increase bleeding risk. Instead, acetaminophen may be used for pain relief as it has less effect on platelet function.

Choice C reason:
Instructing the client to shave with a disposable razor is not advisable. Shaving can cause cuts or nicks, which can lead to bleeding. For clients with thrombocytopenia, using an electric razor is safer because it reduces the risk of skin lacerations.

Choice D reason:
Initiating protective isolation for the client with thrombocytopenia is not typically necessary unless the client has an additional condition that warrants it, such as an immunocompromised state. Thrombocytopenia itself does not require isolation; instead, precautions to prevent bleeding are the priority.

A. Peripheral edema B. Hypertension C. Pallor D. Pruritus

Correct Answer is D

Explanation

Choice A Reason:
Peripheral edema is the swelling of tissues, typically in the lower limbs, due to the accumulation of fluid. It's not a common sign of anaphylaxis. Anaphylaxis usually involves symptoms like hives, itching, and flushed or pale skin. Peripheral edema can be associated with other conditions such as heart failure, kidney disease, or venous insufficiency.

Choice B Reason:
Hypertension, or high blood pressure, is not typically a symptom of anaphylaxis. During an anaphylactic reaction, the patient is more likely to experience hypotension, or low blood pressure, due to vasodilation and the release of mediators from mast cells and basophils. Hypertension might be present in other medical scenarios but not usually in anaphylaxis.

Choice C Reason:
Pallor, which refers to paleness or a decrease in skin pigmentation, is not a direct symptom of anaphylaxis. Anaphylaxis can cause flushed or pale skin, but this is due to the sudden drop in blood pressure and shock, rather than a primary change in skin color. Pallor is more commonly associated with anemia or blood loss.

Choice D Reason:
Pruritus, or itching, is a common symptom of anaphylaxis and is often accompanied by hives and other skin reactions. It occurs due to the release of histamine and other chemicals from mast cells in the skin. Pruritus is an early warning sign and can precede more severe symptoms of anaphylaxis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus. Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis?

Correct Answer is D

Explanation

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