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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The patient has been diagnosed with type 2 diabetes and reports following a reduced-calorie diet but has not lost any weight. This suggests that the patient may not be following the diet as prescribed or may have other factors affecting their blood glucose levels. Additionally, the patient did not bring their glucose monitoring record, which is an important tool for assessing blood glucose control over time.
In this situation, obtaining a fasting blood glucose level or an oral glucose tolerance test may provide a snapshot of the patient's blood glucose level at the time of the test, but these tests do not provide information about blood glucose control over the past few months. A urine dipstick for glucose is a less reliable method for assessing blood glucose control and is not recommended for routine monitoring.
Therefore, obtaining a glycosylated hemoglobin (HbA1c) level is the most appropriate test in this situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is recommended for routine monitoring of blood glucose control in patients with diabetes. This test can provide valuable information about the effectiveness of the patient's diet and any other interventions aimed at controlling their blood glucose levels.
Correct Answer is C
Explanation
The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.
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