A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence.Which of the following interventions should the nurse recommend?
Limit the client's fluid intake to 1500 m/day.
Assist the client to the restroom 30 min after meals.
Limit the client's physical activity until bowel continence is achieved.
Instruct the client to limit their intake of high-fiber foods.
The Correct Answer is B
Choice A rationale
Limiting fluid intake to 1500 mL/day is not recommended for bowel training. Adequate fluid intake is important for maintaining regular bowel movements and preventing constipation. Limiting fluids can worsen constipation and interfere with bowel training.
Choice B rationale
Assisting the client to the restroom 30 minutes after meals takes advantage of the gastrocolic reflex, which stimulates bowel movements following food intake. This helps establish a regular bowel routine and manage fecal incontinence.
Choice C rationale
Limiting physical activity is not advised for bowel continence. Regular physical activity promotes gastrointestinal motility and overall bowel health. Physical inactivity can lead to constipation and negatively impact bowel training efforts.
Choice D rationale
High-fiber foods are important for bowel health as they add bulk to stool and promote regular bowel movements. Limiting intake of high-fiber foods can lead to constipation and is counterproductive to bowel training.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Kussmaul respirations are deep, labored breathing patterns associated with metabolic acidosis, commonly seen in severe hyperglycemia and diabetic ketoacidosis.
Choice B rationale
Diaphoresis, or sweating, is typically associated with hypoglycemia rather than hyperglycemia. Hyperglycemia often leads to dehydration and dry skin.
Choice C rationale
Urinary ketones are typically present in cases of severe hyperglycemia and diabetic ketoacidosis. Absence of urinary ketones does not indicate hyperglycemia.
Choice D rationale
Chvostek's sign, a twitching of facial muscles, is indicative of hypocalcemia rather than hyperglycemia. It is not a reliable indicator of high blood sugar levels.
Correct Answer is D
Explanation
Choice A rationale
Administering ibuprofen to a client with thrombocytopenia is contraindicated because it can further impair platelet function and increase the risk of bleeding. Alternative pain management options should be considered.
Choice B rationale
Instructing the client to shave with a disposable razor increases the risk of cuts and bleeding. An electric razor is safer for clients with thrombocytopenia due to its lower risk of causing injury.
Choice C rationale
Protective isolation is not necessary for thrombocytopenia. It is primarily used for clients with severe immunocompromise to protect them from infections. Thrombocytopenia management focuses on bleeding prevention.
Choice D rationale
Checking the client for ecchymosis is important because it indicates spontaneous bleeding under the skin, which is a common complication of thrombocytopenia. Monitoring for signs of bleeding helps manage and prevent serious outcomes.
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