A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

encourage the patient to drink at least 3000 ml of ﬂuid a day.

suggest that the patient increase dietary intake of foods that are high in fiber.

inform the patient that a daily bowel movement is not necessary.

perform a focused nursing assessment to identify risk factors for constipation.

Answer and Explanation

The Correct Answer is D

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

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Correct Answer is A

Explanation

acromegaly typically causes an enlargement of the hands and feet. The nurse can inquire if the patient has noticed any changes in shoe size, as this may indicate abnormal growth.

"Are you experiencing tremors or anxiety" is not directly related to acromegaly, and although anxiety can be associated with some medical conditions, it is not a typical symptom of acromegaly.

"Is there any family history of acromegaly?" is also a relevant question, as acromegaly can be caused by a genetic disorder. If the patient has a family history of the condition, this may increase their risk of developing it.

"Have you had a recent head injury?" is not specifically related to acromegaly, although head trauma can cause a variety of medical conditions.

Overall, option a. is the most relevant question to ask a patient with suspected acromegaly.

A. You really should not worry about how you look in the hospital, we see many worse things. B. Most of the physical and mental changes caused by the disease will gradually improve after surgery. C. "Let me show you how to dress so that the changes are not so noticeable." D. "I do not think you look bad; your appearance is just altered by your disease.

Correct Answer is B

Explanation

This response acknowledges the patient's concerns and provides reassurance that the changes are temporary and will improve after surgery. Response is dismissive of the patient's concerns and may make the patient feel unheard. Response c may be helpful, but it does not address the patient's emotional concerns. Response d is not accurate because the patient has expressed feeling awful about their appearance.

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A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

Correct Answer is A

Explanation

A patient with crushing syndrome is admited to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the patient tells the nurse "The worst thing about this disease is how terrible I look; I feel awful about it.' The best response by the nurse is:

Correct Answer is B

Explanation

After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

Mr. D receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between:

Mr. G was newly diagnosed with type 2 Diabetes Mellitus, he asks the nurse what "type 2” means in relation to diabetes. The nurse to the patient that type 2 diabetes diﬀers from type 1 diabetes in that with type 2 diabetes:

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A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?