A client's stool is clay in color. What additional information should the nurse obtain from this client? Select all that apply.
History of alcohol abuse
Intolerance to fatty foods
Pain in the RUQ radiating to the shoulder.
Pain in the McBurney's point
Bleeding ulcer
Correct Answer : A,C,E
Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.
Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.
Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.
Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.
Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.
Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.
Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.
Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.
Correct Answer is D
Explanation
Choice A Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
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