A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrhythmias

Dilated pupils

Gastric ulcer

Diarrhea

Answer and Explanation

The Correct Answer is A

A) Dysrhythmias:
Straining while defecating can trigger the Valsalva maneuver, which involves taking a deep breath and bearing down. This can lead to increased intrathoracic pressure, decreased venous return to the heart, and subsequently a sudden drop in blood pressure when the strain is released. These changes can cause cardiac dysrhythmias, particularly in older adults or those with underlying heart conditions.

B) Dilated pupils:
Dilated pupils are not a known consequence of straining while defecating. Pupillary dilation is typically associated with responses to low light, certain medications, or neurological conditions, rather than gastrointestinal strain.

C) Gastric ulcer:
Gastric ulcers are caused by factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive stomach acid. Straining during defecation does not contribute to the development of gastric ulcers.

D) Diarrhea:
Straining while defecating is more likely to be associated with constipation rather than diarrhea. Diarrhea involves frequent, loose, or watery stools, whereas straining typically occurs due to hard stools and difficulty passing them.

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Correct Answer is D

Explanation

A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.

B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.

C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.

D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.

A. Lavender B. Orange C. Peppermint D. Ginger

Correct Answer is A

Explanation

A. Lavender:
Lavender essential oil is well-known for its calming and relaxing properties. It is often used to promote sleep and alleviate insomnia symptoms. Research suggests that inhaling lavender aroma or using lavender oil in aromatherapy can help improve sleep quality by reducing anxiety and promoting relaxation.

B. Orange:
While orange essential oil has a refreshing and uplifting scent, it is not typically used to promote sleep. Instead, it is often used to boost mood and energy levels due to its citrusy aroma.

C. Peppermint:
Peppermint essential oil has a stimulating and invigorating scent, making it more suitable for promoting alertness and mental clarity rather than inducing sleep. It is commonly used to alleviate fatigue and increase focus.

D. Ginger:
Ginger essential oil has a warm and spicy aroma that is often used for its energizing and revitalizing effects. Similar to peppermint, ginger is not typically used to promote sleep but may help alleviate fatigue and increase mental alertness.

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A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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