The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.

A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.

B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.

C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.

D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.