The nurse is assisting with the care of a client.

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors is unnecessary and may increase feelings of isolation. Social support from friends and peers can enhance emotional adjustment and motivation during rehabilitation.

B. Instruct the client to ignore phantom pain sensations: Ignoring phantom limb pain is not effective; the client should be taught coping strategies, pain management techniques, and report persistent pain to the healthcare team for appropriate interventions.

C. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support provides encouragement, realistic expectations, and shared coping strategies. This intervention can enhance the client’s adjustment and promote psychological well-being.

D. Ask the client to describe her feelings about the loss of the affected limb: Encouraging the client to express emotions supports grief processing and emotional adjustment. Open communication helps the nurse assess psychological needs and provide targeted support.

E. Suggest that family members bring clothing for the client from home: Familiar clothing can increase comfort, provide a sense of normalcy, and support the client’s dignity and autonomy during rehabilitation. Personal items contribute to a supportive healing environment.

A. Request the client to be NPO.: Keeping the client NPO may be necessary if bowel obstruction or severe ileus is suspected, but this action does not immediately promote bowel motility. It is more of a precautionary measure rather than an intervention that addresses the cause of hypoactive sounds.

B. Administer a glycerin suppository.: Suppositories stimulate rectal emptying but do not address slowed peristalsis higher in the gastrointestinal tract. Using a suppository when bowel sounds are hypoactive can worsen discomfort if motility is impaired. This option should only be considered once intestinal activity begins to return.

C. Offer an analgesic medication.: Although pain control is important, many analgesics—especially opioids—can further reduce bowel motility. Giving them before trying non-pharmacologic interventions may worsen the client’s symptoms. Managing pain should follow after attempts to promote movement of the gastrointestinal tract.

D. Ambulate the client in the hallway.: Ambulation is the most effective initial intervention because it stimulates peristalsis and helps resolve postoperative ileus. Movement increases blood flow and activates gastrointestinal muscle activity, which can improve bowel sounds. Early mobility is a priority in postoperative care to restore bowel function.