A client is experiencing constipation.
What should the nurse instruct the client to do to help minimize this problem?
Hold your breath when bearing down to have a bowel movement.
Drink 1,000 milliliters (mL) of fluid a day.
Include more bananas in your diet.
Incorporate exercise into your daily routine.
The Correct Answer is D
Choice A rationale
Holding the breath while bearing down is known as the Valsalva maneuver. This action increases intrathoracic and intra-abdominal pressure, which can lead to a sudden drop in heart rate and a subsequent rise in blood pressure when the breath is released. This can be dangerous for clients with cardiovascular disease and does not address the underlying cause of constipation. It is not a recommended technique for promoting healthy or efficient bowel movements.
Choice B rationale
While increasing fluid intake is essential for treating constipation, 1000 milliliters per day is generally insufficient for most adults. Standard recommendations usually suggest at least 2000 to 3000 milliliters of fluid daily to keep the stool soft and facilitate its passage through the colon. Inadequate fluid intake allows the colon to absorb more water from the waste, resulting in hard, dry stools that are difficult and painful to evacuate during defecation.
Choice C rationale
Bananas are often included in the BRAT diet, which is used to manage diarrhea because they can have a binding effect on the stool. While they contain some fiber, they are not the primary fruit recommended for relieving constipation. High-fiber foods like prunes, pears, or leafy greens are more effective at increasing stool bulk and stimulating peristalsis. Relying on bananas might not provide the necessary stimulus to resolve a client's chronic or acute constipation.
Choice D rationale
Physical activity is a primary intervention for constipation because exercise stimulates peristalsis, which is the rhythmic contraction of the intestinal muscles that moves waste through the digestive tract. Even moderate activity, such as walking, can significantly decrease the transit time of stool in the large intestine. This limits the amount of water absorbed by the colon, keeping the stool softer and easier to pass, thereby directly addressing the physiological slowing associated with constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Color is a primary physical characteristic of urine that provides immediate clinical data regarding hydration and health. Normal urine ranges from pale yellow to deep amber depending on the concentration of urochrome. Abnormal colors can indicate pathological states, such as hematuria causing red urine or bilirubinuria causing tea-colored urine. Monitoring color helps identify potential renal or systemic issues and ensures the nurse can report significant deviations from the expected straw-colored appearance.
Choice B rationale
Specific gravity measures the concentration of particles in urine and reflects the ability of the kidneys to concentrate or dilute urine effectively. The normal range for specific gravity is typically 1.005 to 1.030. High values suggest dehydration or high solute loads, while low values may indicate overhydration or renal failure where the kidneys cannot concentrate waste. Assessing this characteristic is crucial for evaluating fluid balance and renal tubular function in various clinical scenarios.
Choice C rationale
Turbidity refers to the clarity or cloudiness of the urine sample. Freshly voided urine should normally be clear or transparent. Cloudiness or increased turbidity can be caused by the presence of bacteria, white blood cells, red blood cells, vaginal discharge, sperm, or crystals. Persistent turbidity often indicates a urinary tract infection or the presence of significant sediment. Observing clarity is a simple but effective bedside tool for screening for inflammatory or infectious processes.
Choice D rationale
The pH of urine indicates the acidity or alkalinity of the fluid, reflecting the kidneys' role in maintaining acid-base balance. The normal range for urine pH is 4.6 to 8.0, with an average of 6.0. Changes in pH can occur due to diet, metabolic conditions, or the presence of certain bacteria like Proteus, which makes urine more alkaline. Monitoring pH is essential in managing stone formation risk and identifying metabolic disturbances that affect systemic homeostasis.
Choice E rationale
Odor is a distinct characteristic that changes based on diet, hydration, and disease. Normal urine has a faint aromatic smell, but as it stands, it may smell of ammonia due to bacterial breakdown. Foul-smelling urine often suggests a urinary tract infection, while a sweet, fruity odor can indicate diabetic ketoacidosis due to the presence of ketones. Recognizing these odors allows the nurse to initiate further diagnostic testing and address potential metabolic or infectious complications.
Correct Answer is D
Explanation
Choice A rationale
The lithotomy position involves the client lying on their back with hips and knees flexed and thighs apart, often supported in stirrups. This position is primarily used for vaginal examinations, childbirth, or urological procedures. It does not facilitate the natural flow of enema solution into the sigmoid colon and rectum. Furthermore, this position can be uncomfortable and does not utilize gravity to assist in the distribution of the fluid throughout the lower descending colon segment.
Choice B rationale
The supine position, where the client lies flat on their back, is inappropriate for enema administration. In this position, the rectum is not aligned to allow for the easy passage of the rectal tube or the efficient flow of the enema solution. Gravity would work against the fluid moving deeper into the colon, likely resulting in poor retention and ineffective results. It also increases the risk of the client feeling immediate pressure and expelling the fluid prematurely.
Choice C rationale
Semi-Fowler's position involves the client sitting up with the head of the bed at a 30 to 45 degree angle. This position is typically used to promote lung expansion or reduce the risk of aspiration. It is not suitable for enema administration because the upright angle of the torso makes it difficult to access the rectum properly. Additionally, gravity would cause the fluid to pool in the rectum rather than flowing higher into the sigmoid colon for cleansing.
Choice D rationale
Left Sims' position, where the client lies on the left side with the right knee flexed toward the chest, is the preferred position for an enema. This position allows the enema solution to flow by gravity along the natural curve of the sigmoid colon and the descending colon. This facilitates deeper penetration of the fluid and better retention, leading to more effective bowel stimulation. It also provides the nurse with optimal visualization and access to the anal area.
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