The nurse is caring for a client from another culture. The client tells the nurse that he is constipated. What is the nurse's initial action?
A) Encourage the client to increase fluid intake and activity.
B) Assess the client's intake of fiber and fluids.
C) Determine what the client means by constipation.
D) Obtain an order for a laxative and an enema from the physician.
Answer: C
The nurse should first carefully evaluate the client's concern and question the person as to what is meant by constipation. Determining the client's normal frequency of bowel movement, consistency of stool, and effort in passing stool is important before deciding to act. The other suggestions-achieving adequate fluid intake, exercising, including fiber in the diet, and using a laxative (and possibly an enema)-may be appropriate once the nurse has adequately assessed the client's concern of constipation
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