The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurse's initial intervention for this client is to:
1. Determine if the client has been eating sufficiently, especially fiber-rich foods
2. Determine how long it has been since the client had a normal-size, formed stool
3. Perform a digital examination of the rectum to determine the presence of stool
4. Call the health care provider to get a prescription for an antidiarrheal medication
ANS: 1
When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the colon seeps around the impacted mass. An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital exam-ination should be performed after it has been determined that the client has been without a nor-mal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention.
You might also like to view...
The nurse is aware that magnesium deficiency is a potential nutritional problem in the United States. What is the cause of this potential problem?
A) Low intake of milk and dairy products B) Not eating enough citrus fruits in our diet C) Not drinking enough enriched orange juice D) The use of refined grains over whole grains
A new nurse is working with a client who is experiencing amnesia. The new nurse recalls that according to psychodynamic theory which defense mechanism is primarily used by those experiencing amnesia?
A) Suppression B) Sublimation C) Displacement D) Repression
A child with the diagnosis of acute postinfectious glomerulonephritis may exhibit:
1. Anorexia. 2. Abdominal pain. 3. Malaise. 4. All of the above.
The nurse is reading the laboratory results of a client with a blood disorder and notes there is a positive direct Coombs' test. Which of the following conditions might this test result signify?
A) Leukocytosis B) Thrombocytosis C) Polycythemia vera D) Transfusion reaction