The client has experienced a lower motor neuron injury and as a result has a flaccid bowel elimination pattern with infrequent passage of hard, dry stool. What intervention would be most helpful in relieving this client's constipation?
A. Pouring warm water over the perineum
B. Tapping the abdomen from left to right
C. Daily tap water enemas
D. Manual disimpaction
D
For the client with a lower motor neuron injury, the resulting flaccid bowel may require the client to be manually disimpacted. Scheduled toileting and massaging the abdomen from right to left also may be helpful.
You might also like to view...
A nurse is preparing to assist a nursing student to administer intravenous verapamil to a patient who also receives a beta blocker. The nurse asks the nursing student to discuss the plan of care for this patient
Which statement by the student indicates a need for further teaching? a. "I will check to see when the last dose of the beta blocker was given." b. "I will monitor vital signs closely to assess for hypotension." c. "I will monitor the heart rate frequently to assess for reflex tachycardia." d. "I will prepare to administer intravenous norepinephrine if necessary."
A client's spouse reports the presence of a reddened area on her husband's coccyx. She feels a massage would be helpful in promoting circulation to the area. The nurse responds to this suggestion by saying:
1. "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.". 2. "I will record these findings in the medical record.". 3. "Massaging the area may actually cause more harm to a potentially compromised area of skin.". 4. "I will need to obtain an order from the physician to perform a massage.".
The nurse is preparing a client for inguinal hernia surgery, which will require hair to be removed from the inguinal region. The nurse informs the client that this hair removal is completed at what time in relation to the surgery?
A. The nurse will instruct the client on completing a preoperative shave with a safety razor on the night prior to the surgery. B. The nurse will instruct the client to complete the preoperative shave with a safety razor on the morning of the surgery prior to coming to the hospital. C. The nurse will explain that the preoperative shave will be completed using an electric clipper after the client arrives at the hospital the morning of surgery. D. The nurse will tell the client that the preoperative shave will be completed by the surgeon in the operating room immediately prior to the beginning of the surgery.
A teenage boy has been periodically beaten by his father. The boy tells the nurse, "He'll pay for this one way or another." The nurse treating his contusions should assess for be-haviors suggesting:
a. Aggression b. Depression c. Regression d. Withdrawal