A client from another culture tells the nurse that he is constipated. The initial action by the nurse in this situation is which of the following?

Question

1. Determine what the client means by constipation
2. Obtain an order for a laxative and an enema if needed
3. Encourage the client to increase fluid intake and activity
4. Assess the diet for adequacy of fiber and fluids

Answer 1

1. Determine what the client means by constipation

Rationale:
The nurse should first carefully evaluate the client's concern and question the person as to what he considers to be 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.