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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery.
Elevation promotes venous return and prevents fluid accumulation in the tissues.
Choice A is wrong because applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.
Choice B is wrong because the client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.
Choice C is wrong because numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.
The client should expect these symptoms to improve or resolve after surgery, not persist or worsen. If the client experiences numbness and tingling after surgery, they should report it to the surgeon as it may indicate a complication such as nerve injury or hematoma.
Normal ranges for grip strength, pinch strength, and keypinch strength vary depending on age, sex, and hand dominance. However, a general reference for grip strength is 20 to 40 kg for men and 15 to 30 kg for women. For pinch strength, it is 6 to 12 kg for men and 5 to 10 kg for women. For keypinch strength, it is 4 to 8 kg for men and 3 to 7 kg for women.
These values may be lower in older adults or people with chronic conditions.
The client should expect some loss of strength in the affected hand after surgery, but it should gradually improve with rehabilitation.
Correct Answer is D
Explanation
Choice A reason:
"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.
Choice B reason:
"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.
Choice C reason:
"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.
Choice D reason:
"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.
It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.
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