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?
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.
Administer a cathartic suppository 30 min prior to scheduled defecation times.
The Correct Answer is D
The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A
bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
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Correct Answer is C
Explanation
The leader allows the group to discuss whatever they would like to regarding their medications.
This is because a laissez-faire leadership style is characterized by minimal guidance and direction from the leader, and maximum freedom and autonomy for the followers.
The leader does not impose any rules or expectations on the group, and lets them decide how to manage their own learning and behavior.
Choice A is wrong because having group members vote on what they would like to learn about during the session is an example of a democratic leadership style, not a laissez-faire one.
A democratic leader solicits input and feedback from the group, and makes decisions based on consensus and majority rule.
Choice B is wrong because lecturing about medication adverse effects to the group members is an example of an authoritarian leadership style, not a laissez-faire one.
An authoritarian leader dictates what the group should do and how they should do it, without considering their opinions or preferences.
Choice D is wrong because encouraging group members to remain silent until questions are called for is an example of a paternalistic leadership style, not a laissez-faire one.
A paternalistic leader treats the group as if they are incapable of making their own decisions, and assumes a protective and nurturing role over them.
Normal ranges for leadership styles are not applicable in this context, as different styles may be more or less effective depending on the situation and the goals of the group.
However, some general advantages and disadvantages of each style are:
- Laissez-faire: Advantages - fosters creativity, independence, and self-motivation; Disadvantages - may lead to chaos, confusion, and lack of accountability.
- Democratic: Advantages - promotes participation, collaboration, and satisfaction; Disadvantages - may be time-consuming, inefficient, and conflict-prone.
- Authoritarian: Advantages - provides clarity, direction, and control; Disadvantages - may cause resentment, resistance, and dependency.
- Paternalistic: Advantages - creates trust, loyalty, and commitment; Disadvantages - may inhibit growth, development, and empowerment.
Correct Answer is B
Explanation
The correct answer is choice B. Isolate the client from staff who are pregnant.
Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage.
Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure.
Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate.
Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.
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