The nurse notes that a patient with a history of a myocardial infarction is straining during defecation. Which of the following responses by the nurse is best?
a. "It is important that you not strain because it could cause damage to your heart."
b. "Your blood pressure gets very low when you strain like that and you could faint."
c. "Chronic constipation often causes a dilated colon, so it is good that you are staying empty."
d. "Be careful, you might get a headache when you push so hard."
ANS: A
Straining to have a bowel movement (Valsalva's maneuver) can result in cardiac, neurological, and respiratory complications. If the patient has a history of heart failure, hypertension, or recent myocardial infarction, straining can lead to cardiac rupture and death.
You might also like to view...
A patient is instructed to take diphenhydramine (Benadryl) after an allergic reaction. Which of the following statements by the patient indicates successful teaching concerning the administration of diphenhydramine (Benadryl)?
A) "I will still be able to have my after-dinner drink with this medication." B) "I will eat a diet low in sodium while taking this medication." C) "I should not drive my car after taking this medication." D) "I can take this medication every 2 hours until I feel better."
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.
A nurse who failed to irrigate a feeding tube as ordered resulting in harm to the patient could be found guilty of:
a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the Nurse Practice Act.
The existing health-care delivery system is influenced by trends and issues beyond the health-care system, including:
A) Globalization, standard precautions, and technology B) Societal demographics, economics, and legislation C) Core measures, diversity, and regulation D) Evidence-based practice, system errors, and environment