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.
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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Related Questions
Correct Answer is C
Explanation
A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.
B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.
C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.
D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.
Correct Answer is B
Explanation
A. Xerostomia, or dry mouth, can occur due to various causes, including medications, but it is not an infectious condition linked directly to AIDS.
B. Candidiasis, or oral thrush, is a common opportunistic infection in clients with AIDS due to their weakened immune system and low CD4-T-cell count. It is caused by the overgrowth of Candida species in the mouth.
C. Gingivitis, an inflammation of the gums, can occur in immunocompromised individuals but is not as specific or common in AIDS as candidiasis.
D. Halitosis, or bad breath, can be a symptom of various conditions, including oral infections, but it is not a specific infectious condition associated with AIDS like candidiasis is.
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