A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Take an over-the-counter laxative every morning.

Drink six to eight large glasses of water daily.

Try using over-the-counter enemas when needed.

Walk around the block or further every day.

Answer and Explanation

The Correct Answer is B

A.   While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B.   Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C.   Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D.   Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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Correct Answer is A

Explanation

A. Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B. While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C. Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D. While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

A. Ask the client how often episodes of sun downing are experienced. B. Assist the client with values clarification about end-of-life care options. C. Question the client about the frequency of falls in recent months. D. Request to have the client lie as still as possible for the assessment.

Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

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A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

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