nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container.

Encourage the client to bear down.

Allow the client to expel some fluid before continuing.

Stop the enema and document that the client did not tolerate the procedure.

Answer and Explanation

The Correct Answer is A

A. Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.

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Correct Answer is B

Explanation

A. Osteoarthritis is not known to cause SIADH. It is a degenerative joint disease and does not typically affect antidiuretic hormone regulation.
B. Small Cell Lung cancer is associated with SIADH as it can produce ectopic ADH, leading to increased water retention and dilutional hyponatremia.
C. Dyspepsia is a digestive disorder and is not related to SIADH. It involves discomfort or pain in the upper abdomen.
D. Liver cirrhosis can cause fluid imbalance and hyponatremia, but it is not a primary cause of SIADH. SIADH is more commonly associated with malignancies like Small Cell Lung cancer.

A. Paresthesia B. Paraplegia C. Quadriplegia D. Hemiplegia

Correct Answer is B

Explanation

A. Paresthesia, or abnormal sensation, can occur with spinal cord injuries but is not a primary type of disability specific to injury at T2-T3.
B. Paraplegia, or paralysis of the lower half of the body, is anticipated with a spinal cord injury at the T2-T3 level, affecting the thoracic region and below.
C. Quadriplegia, or paralysis of all four limbs, results from injuries at the cervical spinal cord levels, not the thoracic levels.
D. Hemiplegia, or paralysis on one side of the body, is typically associated with brain injuries or strokes, not spinal cord injuries at T2-T3.

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nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting the medical history from a client who has manifestations of the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH?

Correct Answer is B

Explanation

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Correct Answer is B

Explanation

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