Author Question: The female nurse is administering an enema to a 23-year-old male client with a questionable ... (Read 34 times)

theo · **on:** Jul 22, 2018

The female nurse is administering an enema to a 23-year-old male client with a questionable gastrointestinal blockage. The nurse plans care based on which anticipated reaction by the client?

1. I am afraid of having an enema..
2. I have never had an enema before..
3. I would rather have the doctor do this..
4. May I have a visitor as support in the room?

Question 2

Which of the following assessment findings would indicate that the nurse needs to take immediate action when caring for a client with asthma?

1. Tachycardia, tachypnea, and prolonged expirations
2. Diffuse wheezing and the use of accessory muscles when inhaling
3. Retractions, fatigue, and anxiety
4. Inaudible breath sounds, reduced wheezing, and an ineffective cough

popopong · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. I would rather have the doctor do this..

Rationale:
The nurse would anticipate that most young adults will be embarrassed by this procedure when the nurse and young client are of different genders. When the client states that the doctor could perform the enema, the client is probably acting on embarrassment and on the assumption that the doctor is male. The nurse should approach the client beforehand to address the issue. Most clients would only experience annoyance, not fear for this procedure. A client who has never experienced an enema is exhibiting a lack of knowledge, which is not usually the case for a 23-year-old; most people of that age have had experienced an enema. The nurse would definitely not expect the client to request the presence of another person in the room for an intimate procedure.

Answer to Question 2

4. Inaudible breath sounds, reduced wheezing, and an ineffective cough

Rationale:
Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure. During an asthma attack, tachycardia, tachypnea, and prolonged expirations are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing and the use of accessory muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still occurring; therefore, they do not require the most urgent action. Retractions, fatigue, and anxiety are also a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging.