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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Placing clean linen that touched the floor in the soiled linen bag: This action demonstrates an understanding of infection control principles because it prevents cross-contamination between clean and soiled linens. Placing clean linens that have come into contact with the floor in the soiled linen bag reduces the risk of spreading pathogens and maintains a clean environment for the client.
A) Placing the soiled linen on the floor before bagging it: This action increases the risk of contamination by exposing the linen to potentially contaminated surfaces. Placing soiled linen on the floor can spread pathogens and is not consistent with infection control practices.
C) Holding the soiled linen against her body while carrying it to the linen bag: This action increases the risk of contamination to the AP's clothing and skin. Contact with soiled linen can transfer pathogens to the caregiver's body, leading to the potential spread of infection.
D) Shaking the soiled linen to remove any toilet paper remnants: This action can aerosolize fecal matter and spread pathogens into the air and onto nearby surfaces. Shaking soiled linen increases the risk of contamination and is not recommended as part of infection control practices.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
The rationale for identifying the client as at risk for hypoxia is based on the respiratory assessment findings. Diminished lung sounds in the posterior lobes suggest reduced air movement or potential complications such as atelectasis or pneumonia, which can impair gas exchange. Additionally, the decreased oxygen saturation of 84% on room air indicates inadequate oxygenation of the blood. Hypoxia occurs when there is insufficient oxygen supply to tissues, which can lead to serious complications if not addressed promptly. Therefore, recognizing these respiratory assessment findings is crucial for identifying the risk of hypoxia in the client.
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