Nokea
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?
- A. Digitally check the client for a fecal impaction
- B. Increase fluid intake to promote bowel regularity
- C. Provide a high-fiber diet to facilitate bowel movements
- D. Administer a stool softener
Correct Answer: A
Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.
You may also like to solve these questions
The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?
- A. A client who is two days post knee surgery and describes pain at a "4" on a 1 to 10 scale
- B. A client who is one day post bowel resection with no bowel sounds
- C. A client who is 8 hours post appendectomy with urinary output of 480 ml
- D. A client who was admitted with severe abdominal pain and suddenly has no pain
Correct Answer: D
Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.
A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first?
- A. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg
- B. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap
- C. Measure and record the infant's frontal-occipital circumference
- D. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis
Correct Answer: B
Rationale: The correct first action for a newborn potentially exposed to HIV is to bathe the infant with dilute chlorhexidine or soap. This helps reduce the risk of infection. Initiating treatment with zidovudine would be important but not the first priority. Measuring and recording the infant's frontal-occipital circumference and administering vitamin K are important tasks but are not the priority when dealing with potential HIV exposure. Immediate hygiene measures are crucial to minimize the risk of transmission.
In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?
- A. Ineffective coping related to uncertainty of disease progression
- B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
- C. Ineffective breathing pattern related to ascending paralysis
- D. Impaired physical mobility related to asymmetrical descending paralysis
Correct Answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.
A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor urine output hourly
- B. Assess for back muscle aches
- C. Record drainage from the drain
- D. Obtain body weight daily
Correct Answer: C
Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.
A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?
- A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
- B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
- C. Inform the client that his mother's schizophrenia has affected his psychological development.
- D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.