A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
Check the client's medical record for the provider's prescription.
Inform the charge nurse that the client refused the enema.
Explain to the client that the provider prescribed the procedure.
Assure the client that enemas are commonly prescribed for constipation.
The Correct Answer is A
Rationale:
A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.
B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.
C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.
D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.
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Correct Answer is B
Explanation
Rationale:
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C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.
D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.
Correct Answer is C
Explanation
Rationale:
A. Defamation of character involves damaging someone’s reputation, which is not relevant in this context.
B. Slander involves spoken defamation, not applicable here.
C. False imprisonment refers to the unlawful restraint or restriction of an individual’s freedom, which can occur with unauthorized use of restraints.
D. Invasion of privacy involves unauthorized access to personal information or space, not directly related to the use of restraints.