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 D
Explanation
Choice A Reason: Ice cream is not a good food choice for a client who has cholecystitis, as it is high in fat and may trigger gallbladder pain or inflammation.
Choice B Reason: Blueberry muffin is not a good food choice for a client who has cholecystitis, as it may contain butter, oil, or eggs that are high in fat and may aggravate gallbladder symptoms.
Choice C Reason: Macaroni and cheese is not a good food choice for a client who has cholecystitis, as it is high in fat and cholesterol and may cause gallstone formation or obstruction.
Choice D Reason: Roast turkey is a good food choice for a client who has cholecystitis, as it is low in fat and high in protein and may help to prevent gallbladder attacks.
Correct Answer is D
Explanation
Choice A Reason: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.
Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.
Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.
Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.
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