Nokea
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Correct Answer: C
Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.
You may also like to solve these questions
The client is receiving chemotherapy for breast cancer. Which instruction should the nurse include to prevent infection?
- A. Avoid crowds and people with colds.'
- B. Take your temperature twice a week.'
- C. Eat only well-cooked meats.'
- D. Use a soft toothbrush for oral care.'
Correct Answer: A
Rationale: Chemotherapy causes immunosuppression, increasing infection risk. Avoiding crowds and sick individuals reduces exposure to pathogens. The other measures are helpful but less effective at preventing infection.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
The client is prescribed prednisone for an acute exacerbation of lupus. Which side effect should the nurse monitor for?
- A. Hypoglycemia
- B. Weight loss
- C. Hypertension
- D. Bradycardia
Correct Answer: C
Rationale: Prednisone, a corticosteroid, can cause hypertension due to sodium retention and vasoconstriction. Hyperglycemia (not hypoglycemia), weight gain, and tachycardia are more likely than weight loss or bradycardia.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Correct Answer: A
Rationale: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid 'vena caval syndrome,' a condition which:
- A. Occurs when blood pressure increases sharply with changes in position
- B. Results when blood flow from the extremities is blocked or slowed
- C. Is seen mainly in first pregnancies
- D. May require medication if positioning does not help
Correct Answer: B
Rationale: Vena caval syndrome occurs when the gravid uterus compresses the inferior vena cava, slowing blood return from the extremities.