A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
Administer a cathartic suppository 30 min prior to scheduled defecation times.
Encourage a maximum fluid intake of 1,500 mL per day.
Increase the amount of refined grains in the client's diet.
Provide the client with a cold drink prior to defecation.
The Correct Answer is A
A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.
B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.
C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.
D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Referring the adolescent to a mental health clinic is not the primary action to address her concerns about affording and caring for her baby.
B. Incorrect. Advising adoption might not be appropriate if the adolescent wants to explore options for keeping and caring for her baby.
C. Incorrect. Contacting the adolescent's parent for assistance may not be feasible or appropriate if the adolescent's situation does not allow for parental involvement.
D. Correct. Assisting the adolescent in applying for Medicaid is a practical step to help her access financial assistance for her pregnancy-related care and the care of her baby.
Correct Answer is C
Explanation
Choice A rationale:
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
Choice B rationale:
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
Choice C rationale:
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
Choice D rationale:
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.
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