A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?
Insert a rectal tube at specified intervals.
Assist to a bedside commode 30 minutes after meals.
Encourage the use of incontinence briefs.
Administer a glycerin suppository 15 minutes after meals.
The Correct Answer is B
Choice A rationale
Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.
Choice B rationale
Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.
Choice C rationale
Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.
Choice D rationale
Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.
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Correct Answer is D
Explanation
Choice A rationale
Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.
Choice B rationale
Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.
Choice C rationale
Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.
Choice D rationale
Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.
Correct Answer is C
Explanation
Choice A rationale
Telling the parents that their child’s medical information is none of their business is not appropriate. It is important to communicate respectfully and explain the legal status of the emancipated minor.
Choice B rationale
Promising to give the results to the parents as soon as they are back from the laboratory is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.
Choice C rationale
Informing the parents that the nurse can only give medical information to their child because they are legally an adult is the best response. This explains the legal status of the emancipated minor and respects their autonomy.
Choice D rationale
Telling the parents that the healthcare provider will share the information with them is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.