Risk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury (SCI)
The nurse would plan which interventions to address this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check each stool for occult blood.
2. Administer stool softener as prescribed.
3. Institute chemical stimulation to initiate bowel evacuation.
4. Place the patient in an adult incontinence garment.
5. Manage parenteral feedings as ordered.
2,3,5
Rationale 1: Testing stool for occult blood is directed toward monitoring for a bleeding gastric ulcer. This patient has a potential for gastric ulceration related to the stress of this critical injury.
Rationale 2: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of stool softener to help establish a regular bowel elimination pattern.
Rationale 3: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of chemical stimulation such as a suppository to establish a regular bowel elimination pattern. The patient's bowel elimination pattern should be monitored closely to ensure adequate bowel evacuation.
Rationale 4: There is no indication that an incontinence garment is necessary.
Rationale 5: Early nutritional support is often achieved through parenteral feedings until enteral feedings are introduced and tolerated.
You might also like to view...
The nurse knows that teaching has been effective when the clients state that upon awakening following electroconvulsive therapy they:
1. Should be assisted to ambulate. 2. May have water immediately. 3. May be confused and disoriented. 4. Should eat breakfast.
Which patient information is essential for the nurse to provide the physician who is preparing to administer conscious sedation to a patient?
Select all that apply. 1. The patient has a history of snoring. 2. The patient drank a cup of coffee two hours ago. 3. The patient wants to be asleep for the procedure. 4. The patient's father was hypertensive. 5. The patient has a history of gout.
A client is prescribed lactated Ringer's (LR) solution for a surgical procedure. The nurse understands that the purpose for prescribing these IV fluids is:
a. LR is an isotonic solution that will help maintain the client's normal osmotic pressure. b. LR is the most commonly prescribed IV fluids for clients during and following surgery. c. LR is a hypertonic solution necessary to promote renal perfusion during surgery. d. LR is a hypotonic solution necessary to promote renal perfusion following surgery.
The nurse admits the adult client who has unexplained weight gain. Which client data warrants further investigation?
1. One bowel movement daily is normal. 2. Postprandial stomach rumbling is loud. 3. Abdominal girth increases on 1200 kcal/day. 4. Stretch marks do not fade with applied lotion.