Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.

Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.

Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.

The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.

Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.

The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.

Calling her parents without her permission may violate her privacy and autonomy.

Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.

The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.

Security measures can be taken later if needed.

The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.

This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.

Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.

The surgeon may order interventions based on the assessment findings.

Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.

The nurse should encourage fluid intake only after ensuring adequate urinary output.

Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.

Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.

Normal urine output is about 30 mL per hour or 240 mL in eight hours.

The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.

Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.