A nurse is caring for a patient who is on bed rest and is experiencing constipation.
Which of the following interventions should the nurse implement?

Increase the patient’s fluid intake.

Place the patient on a low-fiber diet.

Request a prescription for mineral oil for the patient.

Encourage the patient to drink cold fluids.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Increasing fluid intake can help alleviate constipation. Fluids can soften stool, making it easier to pass.
Choice B rationale
A low-fiber diet can actually contribute to constipation. Fiber adds bulk to the stool and helps it move more quickly through the intestines.
Choice C rationale
While mineral oil can sometimes be used to relieve constipation, it is not typically the first intervention chosen. It can interfere with the absorption of certain nutrients and medications.
Choice D rationale
Cold fluids do not have a significant effect on constipation. While staying hydrated is important, the temperature of the fluids is not typically a factor in constipation.

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Correct Answer is B

Explanation

Choice A rationale
While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.

A. Check the patient’s visual acuity using a Snellen chart. B. Whisper in one of the patient’s ears while blocking the other. C. Observe the patient’s ability to turn their head from side to side. D. Ask the patient to identify specific smells. E. Ask the patient to identify specific smells.

Correct Answer is C

Explanation

Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.

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A nurse is caring for a patient who is on bed rest and is experiencing constipation. Which of the following interventions should the nurse implement?

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A nurse is caring for a patient who is on bed rest and is experiencing constipation.
Which of the following interventions should the nurse implement?