The nurse determines the client requires fecal impaction removal. Which assessment finding justifies the nurse's decision?
1. Client exhibits rebound tenderness.
2. Client is unable to expel hard stool.
3. Client has history of fecal impaction.
4. Client denies bowel movement today.
2
2. The nurse determines that the client who is unable to pass hard stool requires fecal removal after unsuccessful methods, including suppositories and enemas.
1. Rebound tenderness is a clinical indicator consistent with peritonitis. Normal pain and tenderness, however, can indicate stool impaction.
3. A client history of fecal impaction affects prevention strategies for impaction in-cluding exercise, fluids, high-fiber diet, and maintaining a bowel ritual and regular bowel habits.
4. Clients can expel small, hard stool or diarrhea-stool with impacted stool.
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