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 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.
Correct Answer is D
Explanation
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.