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 B
Explanation
Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.
Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.
Correct Answer is C
Explanation
The correct answer is choicec. The cobalamin injections will prevent me from becoming anemic.
Choice A rationale:
Cobalamin (B12) injections do not increase hydrochloric acid production in the stomach.Chronic atrophic gastritis often leads to decreased production of hydrochloric acid due to the loss of parietal cells, but B12 injections do not reverse this condition.
Choice B rationale:
The need for cobalamin injections is typically lifelong in patients with chronic atrophic gastritis because the condition leads to a permanent loss of intrinsic factor, which is necessary for B12 absorption. The injections are not just until the stomach heals.
Choice C rationale:
Chronic atrophic gastritis can lead to vitamin B12 deficiency due to the loss of intrinsic factor, which is essential for B12 absorption.This deficiency can cause pernicious anemia, and B12 injections are necessary to prevent this condition.
Choice D rationale:
While chronic atrophic gastritis does increase the risk of stomach cancer, B12 injections are not specifically aimed at reducing this risk.The primary purpose of B12 injections is to prevent anemia.
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