The nurse is caring for a patient with a history of dementia who is incontinent of stool because she cannot communicate the need to defecate. What is the priority action of the nurse?

Question

a. Administer a daily laxative and take the patient to the toilet afterward.
b. Digitally remove stool from the patient's rectum every other day.
c. Insert a rectal tube to facilitate drainage of soft or liquid stool.
d. Begin a prompted toileting program to facilitate bowel continence.

Answer 1

ANS: D
Patients who cannot communicate the need to use the toilet often benefit from a prompted toileting program in which the patient is brought to the toilet at the same times each day to promote urinary and bowel continence. A rectal tube should not be used. Digital disimpaction should be avoided whenever possible. Laxatives should be used only when absolutely necessary because continued use will lead to dependence.