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?

Assist the client to the restroom 30 min after meals.

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

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Assisting the client to the restroom 30 minutes after meals is correct recommendation. This intervention aligns with the natural response of the gastrocolic reflex, which often leads to increased colonic motility after eating. Timing the restroom visit to this period can take advantage of the body's natural tendency to have a bowel movement after meals, potentially aiding in achieving bowel continence.

Choice B Reason:

Limiting the client's physical activity until bowel continence is achieved is not appropriate. Physical activity can actually stimulate bowel function and regularity. Moderate physical activity, as appropriate for the client's condition, can promote regular bowel movements. Restricting physical activity might hinder the overall success of bowel training.

Choice C Reason:

Limiting the client's fluid intake to 1500 mL/day is not appropriate. Adequate hydration is crucial for bowel health and regularity. Limiting fluid intake could lead to dehydration and constipation, which can exacerbate fecal incontinence. It's important to encourage adequate hydration unless there are specific medical reasons to restrict fluids.

Choice D Reason:

Instructing the client to limit their intake of high-fiber foods is incorrect. High-fiber foods are beneficial for bowel regularity and can help manage fecal incontinence by promoting healthy bowel movements. Limiting high-fiber foods could potentially lead to constipation or exacerbate the issue of fecal incontinence.

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Correct Answer is C

Explanation

Choice A Reason:

Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.

Choice B Reason:

Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.

Choice C Reason:

Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.

Choice D Reason:

Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.

A. Leave the television on. B. Install locks at the top of doors. C. Place throw rugs on the floor. D. Schedule alternate caregivers.

Correct Answer is B

Explanation

Choice A Reason:

Leaving the television on is incorrect. Constant background noise from the television might be overwhelming and confusing for someone with Alzheimer's. It's generally better to have a quiet and calming environment to reduce agitation and confusion.

Choice B Reason:

Installing locks at the top of doors is correct. This can be an essential safety measure to prevent the person from wandering or accessing unsafe areas. Installing locks higher up on doors can help prevent the individual from opening doors and wandering into potentially dangerous situations.

Choice C Reason:

Placing throw rugs on the floor is incorrect. Throw rugs pose a tripping hazard, especially for individuals with Alzheimer's who might have mobility issues or difficulties with depth perception. Removing throw rugs or securing them firmly to the floor is essential to prevent falls.

Choice D Reason:

Scheduling alternate caregivers is incorrect. While having alternate caregivers is important for support, it doesn't directly relate to environmental modifications within the home.

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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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