A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

"What types of foods have you been eating?”

"Are you using stool softeners or laxatives?”

"Have you been passing gas?”

"Have you had small liquid stools?”

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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Correct Answer is A

Explanation

The correct answer is choice A: "I know that I can change my advance directives if I need to in the future."

Choice A rationale:

This statement indicates an understanding of advance directives. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in case they become unable to make decisions themselves. It's important for clients to know that they can update or change their advance directives if their wishes or circumstances change over time.

Choice B rationale:

The statement that the health care surrogate will make decisions as soon as the power of attorney is signed is not accurate. Generally, a health care surrogate's authority to make decisions comes into effect when the primary individual is no longer able to make decisions themselves. Signing a power of attorney alone does not grant immediate decision-making power to the surrogate.

Choice C rationale:

The family generally cannot overrule the decisions made by a designated health care surrogate. Once an individual designates a surrogate and provides clear instructions through advance directives, the surrogate's decisions are legally binding and typically override the family's input.

Choice D rationale:

Advance directives are not universally valid across states. Laws and regulations regarding advance directives can vary significantly from state to state. It's important for clients to understand that if they relocate, they may need to update their advance directives to comply with the laws of the new state.

A. Client is itching from medication. B. Client states, "I started to itch after taking that medication.". C. It appears that the client has a rash from the medication. D. Rash from medication noted.

Correct Answer is B

Explanation

The correct answer is choice B. Client states, "I started to itch after taking that medication."

Choice A rationale:

"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.

Choice B rationale:

"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.

Choice C rationale:

"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.

Choice D rationale:

"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.

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A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Correct Answer is B

Explanation

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A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

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