Which nursing instruction is correct to provide the client following a barium enema?

The client will maintain a low-residue diet.

Sips of fluid may be increased if tolerated.

An enema will be used to clear the bowel.

The stools may be white or clay-colored.

Answer and Explanation

The Correct Answer is B

Sips of fluid may be increased if tolerated. After a barium enema, the client may be allowed to increase fluid intake to help eliminate the barium and prevent constipation.

Option A: The client will maintain a low-residue diet is not a correct answer as it is not necessary after a barium enema.

Option C: An enema will be used to clear the bowel is not a correct answer as the barium enema is itself a type of enema used to visualize the colon.

Option D: The stools may be white or clay-colored is not a correct answer as it is a potential side effect of barium use, not an instruction to the client.

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Correct Answer is C

Explanation

Explanation: When dealing with a client who has been physically aggressive and is in distress, the best approach for the nurse is to use brief statements and questions to obtain essential information. This approach helps to keep the communication clear, focused, and non-threatening. The nurse should maintain a calm and assertive demeanor while avoiding lengthy discussions that may escalate the client's agitation.

Options not appropriate in this situation:

B. Providing close contact to increase the client's sense of safety may not be safe for the nurse or the client, especially when dealing with someone who has been physically aggressive. It is essential to maintain a safe distance and ensure the safety of everyone involved.

C. Having a sense of humor to show a lack of fear can be misinterpreted by the client and may not be appropriate or therapeutic in this context. The focus should be on establishing a professional and respectful rapport with the client, prioritizing their needs and safety.

Option D may not be the best approach because open-ended questions could lead to lengthy responses, which may not be suitable for a client who is in distress and potentially aggressive. The nurse should aim for concise and clear communication to ensure safety and facilitate a psychiatric assessment efficiently.

A. The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. B. The client has periorbital edema and ecchymosis. C. The client prefers to rest in the semi-Fowler's position. D. The client's level of consciousness has improved.

Correct Answer is A

Explanation

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. An elevated temperature is a significant finding that may indicate the presence of an infection, which can cause further neurological damage in a client with an intracranial injury. The physician should be notified promptly, as the client may require antibiotic therapy to prevent the spread of infection.

B. Periorbital edema and ecchymosis are normal findings following head injury and should be monitored but do not require immediate intervention.

C. Resting in semi-Fowler's position is an appropriate position to maintain after intracranial pressure-reducing surgery.

D. Improved level of consciousness is a positive finding and indicates that the client is responding well to treatment.

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Which nursing instruction is correct to provide the client following a barium enema?

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