The nurse is assessing a cognitively impaired older adult client and o

The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurse’s initial intervention for this client is to:

1. Determine if the client has been eating sufficiently, especially fiber-rich foods
2. Determine how long it has been since the client had a normal-size, formed stool
3. Perform a digital examination of the rectum to determine the presence of stool
4. Call the health care provider to get a prescription for an antidiarrheal medication

ANSWER

ANS: 1
When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the colon seeps around the impacted mass. An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital exam-ination should be performed after it has been determined that the client has been without a nor-mal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention.