Which word should the nurse use when describing to a client how a soapsuds enema affects the intestine?

Lubricating

Irritating

Dilating

Softening

Answer and Explanation

The Correct Answer is B

A. Lubricating: A lubricating enema typically refers to an enema solution that contains a lubricant, such as mineral oil, to help soften feces and facilitate their passage from the rectum. Lubricating enemas are used to alleviate constipation by easing the passage of stool. However, soapsuds enemas do not primarily function as lubricating enemas.

B. Irritating: This is the correct option. Soapsuds enemas contain soap or detergent mixed with water, and their primary action is to irritate the intestinal mucosa. The irritation stimulates peristalsis, which promotes bowel evacuation. Soapsuds enemas are often used to relieve constipation by inducing bowel movements through irritation of the intestinal lining.

C. Dilating: Dilating refers to widening or enlarging a structure. While enemas, including soapsuds enemas, may contribute to the relaxation and dilation of the rectum and lower bowel, the primary action of a soapsuds enema is to stimulate bowel evacuation through irritation rather than dilation.

D. Softening: Softening enemas typically involve the introduction of a solution, such as a mineral oil-based solution, to soften feces and facilitate their passage from the rectum. While softening enemas help alleviate constipation by softening stool consistency, soapsuds enemas do not primarily function as softening enemas. Their main action is to stimulate bowel evacuation through irritation.

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Correct Answer is B

Explanation

A. 17-year-old who has just had an ankle cast applied: While constipation may occur due to reduced mobility after having an ankle cast applied, teaching about the hazards of straining during bowel movements is not the priority for this client. The immediate concern may be related to cast care and mobility.

B. 60-year-old recovering from a heart attack: This client is recovering from a heart attack, and straining during bowel movements can increase intra-abdominal pressure and potentially lead to complications such as vagal stimulation, which may trigger arrhythmias or further stress the heart. Therefore, teaching about the hazards of straining during bowel movements is essential for this client to prevent complications and promote cardiac safety.

C. 80-year-old admitted for an infected tooth: While constipation may occur as a side effect of certain medications or due to decreased oral intake, teaching about straining during bowel movements is not the immediate priority for this client, given the primary reason for admission is an infected tooth. However, if constipation becomes a concern during the admission, it can be addressed accordingly.

D. 28-year-old new mother of twins: While postpartum mothers may experience constipation due to various factors such as changes in hormone levels, reduced mobility after delivery, and opioid use for pain management, teaching about the hazards of straining during bowel movements may not be the priority compared to other immediate postpartum care needs, such as breastfeeding support, perineal care, and newborn care.

A. Offer toileting reminders every 2 hours B. Provide clothing that is easy to manipulate C. Explain the need to call for the nurse to help with toileting D. Encourage avoidance of fluids between meals

Correct Answer is A

Explanation

A. Offer toileting reminders every 2 hours: This is the best nursing action because it helps prevent urinary incontinence by prompting the client to use the bathroom regularly. Clients with cognitive impairment may have difficulty recognizing the need to void or remembering when to do so. Providing frequent reminders helps maintain bladder continence and reduces the risk of accidents.

B. Provide clothing that is easy to manipulate: While providing clothing that is easy to manipulate can be helpful for clients with cognitive impairment to independently manage toileting, it does not directly address the issue of facilitating bladder continence. Easy-to-manipulate clothing may assist with toileting independence but does not address the need for regular voiding to prevent urinary incontinence.

C. Explain the need to call for the nurse to help with toileting: While educating the client about when to seek assistance for toileting needs is important, it may not be sufficient for facilitating bladder continence in a client with cognitive impairment. Clients may still have difficulty recognizing the need to void or remembering to call for assistance, making frequent reminders more effective in promoting continence.

D. Encourage avoidance of fluids between meals: Encouraging avoidance of fluids between meals is not an appropriate strategy for promoting bladder continence. Restricting fluids can lead to dehydration and other health complications. Maintaining adequate hydration is essential for overall health, and clients should be encouraged to drink fluids regularly throughout the day. Additionally, restricting fluids does not address the underlying issue of cognitive impairment affecting toileting behaviors.

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Which word should the nurse use when describing to a client how a soapsuds enema affects the intestine?

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Naxlex Comprehensive Predictor Exams

The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

Correct Answer is B

Explanation

What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Correct Answer is A

Explanation

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