An older adult woman who is incontinent of stool following a cerebrovascular accident will have which of the following nursing diagnoses?
A) Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate
B) Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency
C) Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence
D) Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis
Ans: A
Feedback:
The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.
You might also like to view...
A client presents to the ambulatory care clinic with complaints of back pain, nausea, and fatigue
When the nurse questions the client about recent stressors the client becomes irritated and states, "I am sick. Why are you asking me about all of this stress stuff?" Which response by the nurse is the most appropriate? 1. "Stress can impact our body by producing a variety of symptoms." 2. "Your nausea and fatigue are most often related to an overabundance of stress in life." 3. "Asking about stress is required for every client." 4. "We all have stress and I need to see how much you have."
A thyroid scan (123I) has been ordered for the patient. The nurse explains it as:
1. "A blood test measures hormones circulating in the bloodstream." 2. "A small needle will be used to remove a tissue sample that will be examined by a cytopathologist." 3. "It is painless and noninvasive. An instrument is moved over the neck area and sound waves will create an image of the gland." 4. "You will be given a liquid to drink, and then a few hours later, they will take images of your neck."
A patient with chronic obstructive pulmonary disease requires intubation
After the physician intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO2 monitor c. V/Q scan d. Pulmonary artery catheter insertion
The nurse is assigned to provide care for a client who has had laparoscopy performed to determine the extent of her endometriosis
Which of the findings in the first 4 hours after the procedure by the nurse will indicate the need to contact the health care provider? 1. Restlessness 2. Shoulder pain 3. Brown-tinged vaginal bleeding 4. Temperature of 99.2?F