A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Assist the client to a left side-lying position with the right knee flexed.

Prepare the client for a chest x-ray.

Administer a cleansing enema.

Auscultate the client’s bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

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Correct Answer is D

Explanation

Choice A rationale

Group discussions can be beneficial for sharing experiences and learning from others, but they do not provide the hands-on, practical experience that is characteristic of the psychomotor learning domain.

Choice B rationale

-answer meetings can be useful for clarifying doubts and enhancing understanding, but they do not offer the opportunity for physical manipulation of objects or execution of procedures, which is central to psychomotor learning.

Choice C rationale

Practice sessions can be an effective method for psychomotor learning as they allow for repeated performance of a skill. However, in the context of teaching adolescents with newly placed ostomies, role play might be more beneficial as it allows for the simulation of real-life scenarios and the practice of problem-solving skills in a safe and controlled environment.

Choice D rationale

Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning. In the context of adolescents with newly placed ostomies, role play can help them practice self-care tasks related to ostomy management in a safe and supportive environment.

A. The client was admitted three days ago. B. The pressure injury was at stage 4. C. The client reported pain as a 2 on a scale from 0 to 10. D. The dressing was reapplied and sealed.

Correct Answer is B

Explanation

Choice A rationale

The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.

Choice B rationale

The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.

The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative

pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.

Choice C rationale

The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.

Choice D rationale

The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.

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A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed. Which of the following methods should the nurse use as a psychomotor approach to learning?

Correct Answer is D

Explanation

Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside. Exhibits Which statement best describes the most critical aspect of the client's pressure injury and current treatment?

Correct Answer is B

Explanation

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