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A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury.

Which of the following actions should the nurse include in the plan of care?

A.

Encourage a maximum fluid intake of 1,500 mL per day.

B.

Increase the amount of refined grains in the client’s diet.

C.

Provide the client with a cold drink prior to defecation.

D.

Administer a cathartic suppository 30 min prior to scheduled defecation times.

Answer and Explanation

The Correct Answer is D

This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or areflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injuries.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.


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Related Questions

Correct Answer is D

Explanation

The correct answer is choice D. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

Moving both crutches with the stronger leg forward first is not correct because in a three-point gait, the two crutches and the affected leg move together, followed by the stronger leg.

Choice B rationale:

Supporting body weight while leaning on the axillary crutch pads is incorrect as this can cause nerve damage under the arms. Weight should be supported by the hands while using crutches.

Choice C rationale:

Stepping with the affected leg first when going up stairs is incorrect. When ascending stairs, the unaffected (stronger) leg should be moved first, followed by the affected leg and crutches.

Choice D rationale:

Positioning both hands on the grips with elbows slightly flexed is correct as it allows for proper weight distribution through the arms and hands, which is essential for balance and safety while using crutches.

Correct Answer is D

Explanation

The correct answer is d. “Your desire to be an organ donor must be documented in writing.”

Rationale for Choice a:

  • Statement:“Your name cannot be removed once you are listed on the organ donor list.”
  • Rationale:This statement is incorrect.Individuals have the right to change their minds about organ donation at any time.They can have their names removed from the organ donor list by contacting the appropriate registry or organization.It's essential for nurses to provide accurate information to ensure informed consent and respect for patient autonomy.

Rationale for Choice b:

  • Statement:“You must be at least 21 years of age to become an organ donor.”
  • Rationale:This statement is also incorrect.The age requirement for organ donation varies by jurisdiction.In many places,individuals under 18 years of age can register as organ donors with parental consent.Nurses should be familiar with local regulations to provide accurate guidance.

Rationale for Choice c:

  • Statement:“I cannot be a witness for your consent to donate.”
  • Rationale:While it's true that nurses generally cannot act as witnesses for organ donation consent,the focus of the response should be on directing the client to the appropriate channels for documentation.Nurses can play a role in facilitating the process by providing information and resources to clients who express interest in organ donation.

Rationale for Choice d:

  • Statement:“Your desire to be an organ donor must be documented in writing.”
  • Rationale:This is the correct response.To ensure clarity and legal validity,organ donation preferences must be documented in writing.This documentation can be done through various means,such as registering with an organ donor registry,indicating preferences on a driver's license,or completing an advance directive.Nurses should emphasize the importance of written documentation to protect the client's wishes.

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