A nurse is teaching a client who has constipation.
Which of the following statements should the nurse include?
Reduce your daily activity.
Try to defecate at different times of the day.
Increase your daily fluid intake.
Consume a low-fiber diet.
The Correct Answer is C
Choice A rationale
Reducing daily activity is not advised for clients with constipation. Physical activity helps stimulate bowel movements and can relieve constipation.
Choice B rationale
Trying to defecate at different times of the day is not recommended. Establishing a regular bowel routine helps promote consistent bowel movements and can prevent constipation.
Choice C rationale
Increasing daily fluid intake is beneficial for constipation. Fluids help soften stool, making it easier to pass and promoting regular bowel movements.
Choice D rationale
Consuming a low-fiber diet is not advisable for clients with constipation. A high-fiber diet helps bulk up and soften stool, making it easier to pass through the intestines.
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Correct Answer is A
Explanation
Choice A rationale
Reflex incontinence is caused by neurological impairment or damage, such as spinal cord injury, which results in a loss of voluntary control over urination. The bladder muscle contracts involuntarily, causing urine leakage.
Choice B rationale
Overflow incontinence occurs when the bladder cannot empty properly, leading to frequent or constant dribbling of urine. It is not typically associated with nerve damage from spinal cord injury.
Choice C rationale
Stress incontinence is caused by physical movement or activity—such as coughing, sneezing, or heavy lifting—that puts pressure on the bladder, leading to urine leakage. It is not related to nerve damage or neurological conditions.
Choice D rationale
Urge incontinence is characterized by a sudden, intense urge to urinate, followed by involuntary urine leakage. It is usually caused by an overactive bladder or other conditions affecting bladder function, but not directly by nerve damage from spinal cord injury.
Correct Answer is C
Explanation
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.