Nokea
A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.
- A. Scheduled toileting
- B. Stool softeners
- C. High-fiber diet
- D. Daily laxatives
- E. Periodic enemas
- F. Routine exercise
Correct Answer: A,B,C,F
Rationale: Bowel training includes scheduled toileting (A), stool softeners (B), high-fiber diet (C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (D) and periodic enemas (E) are not preferred long-term.
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Which statement by the client regarding sickle cell disease indicates a need for further teaching?
- A. I should avoid strenuous exercise.
- B. I can enjoy one glass of red wine per day.
- C. I will avoid cigarettes and all tobacco products.
- D. I should avoid traveling to places at high altitudes such as Denver.
Correct Answer: B
Rationale: Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- A. Impaired physical mobility related to decreased endurance
- B. Hypothermia r/t decreased metabolic rate
- C. Disturbed thought processes r/t interstitial edema
- D. Decreased cardiac output r/t bradycardia
Correct Answer: D
Rationale: Bradycardia in hypothyroidism can lead to decreased cardiac output, which is life-threatening and thus the highest priority diagnosis.
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
- A. Once per day in the morning
- B. Three times per day with meals
- C. Once per day at bedtime
- D. Four times per day
Correct Answer: B
Rationale: Pancreatic enzymes are taken with meals to aid digestion, as cystic fibrosis impairs pancreatic enzyme production.
The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Correct Answer: D
Rationale: Fresh specimens are critical for accurate CMV culture results, as the virus is labile and degrades quickly.