During a fecal impaction removal, an older client complains of feeling dizzy and cold.
Which intervention should the nurse implement?
Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back.
Insert a gloved finger into the rectum and gently massage the rectal sphincter.
Stop the procedure and observe for a reduction in symptoms before continuing.
Encourage the client to take slow, deep breaths while continuing the procedure.
Encourage the client to take slow, deep breaths while continuing the procedure.
The Correct Answer is A
Choice A rationale:
Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.
Choice B rationale:
Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.
Choice C rationale:
Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.
Choice D rationale:
Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Addiction involves a dependence on a substance or behavior that leads to withdrawal symptoms when the substance or behavior is discontinued. The client's handwashing behavior is not related to addiction.
Choice B rationale:
Phobia refers to an irrational and intense fear of a specific object or situation. While the client's avoidance of sitting on chairs in the day area may be related to anxiety, it does not represent a specific phobia.
Choice C rationale:
Compulsion is the correct answer because the client's handwashing ritual is an example of compulsive behavior. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rigid rules. In this case, the client is compelled to engage in the ritual to alleviate anxiety or distress.
Choice D rationale:
Obsession refers to persistent and intrusive thoughts, urges, or images that cause distress and anxiety. While the client's handwashing ritual may be related to obsessive thoughts about cleanliness, the primary clinical behavior being exhibited is the compulsive handwashing itself.
Correct Answer is A
Explanation
Choice A rationale:
Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.
Choice B rationale:
Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.
Choice C rationale:
Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.
Choice D rationale:
Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.
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