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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire extinguisher could potentially help contain a small fire, it's crucial to prioritize rescuing those in immediate danger and alerting others about the fire first by activating the fire alarm. This action ensures that help is on the way and that everyone is aware of the emergency.
Choice B Reason:
Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help contain smoke and fire to some extent, but again, the priority in an emergency situation like this is to rescue those in immediate danger then activate the fire alarm to ensure a swift response and alert others.
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the facility and initiates the emergency response protocol, helping to ensure that help is on the way while potentially preventing the spread of fire. However, this step should be taken after assisting the client to safety as they are in immediate danger.
Choice D Reason:
Assisting the client who is in immediate danger to a nearby common area should be the furst step that the nurse takes before alerting other people of the fire. (RACE protocol)
Correct Answer is B
Explanation
Choice A Reason
Using a hair dryer to blow hot air into the cast is not recommended. It can cause burns, soften the cast material, or create hot spots, potentially leading to skin damage or discomfort for the client.
Choice B Reason:
Perform neurovascular checks of the affected extremity every 2 hours is correct. Performing neurovascular checks regularly is crucial to assess the circulation, sensation, and movement of the affected extremity. This monitoring helps identify any signs of compromised blood flow or nerve function, which could indicate complications such as compartment syndrome.
Choice C Reason:
Positioning the fractured arm below the level of the client's heart is not advisable. Elevating the injured limb above heart level can help reduce swelling and promote blood flow, aiding in the healing process and preventing complications like swelling-related discomfort or decreased circulation.
Choice D Reason:
Immobilizing the client's fingers using a hand splint might not be necessary with a short arm cast. Typically, a short arm cast provides immobilization of the wrist and forearm while allowing some movement and function of the fingers unless specifically directed by the healthcare provider for individual circumstances.
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