A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).

Encourage high-fiber food choices.

Increase fluid intake to 2,000 mL per day.

Encourage ambulation several times per day.

Administer antacids as necessary per bowel management program.

Answer and Explanation

Correct Answer : A,B,C

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.

Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.

They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.

Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.

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Correct Answer is A

Explanation

This is the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.

It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.

This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.

Choice C. Explain the purpose of the medication.

This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.

Choice D. Encourage the client to take the medication.

This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.

A. Decreased blood pressure. B. Increased temperature. C. Impaired physical coordination. D. Nausea and appetite loss. E. Respiratory depression.

Correct Answer is ["A","C","E"]

Explanation

Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.

Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.

Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.

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A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).

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Naxlex Comprehensive Predictor Exams

A client says to the nurse “I will not take the prescribed medication today.” What should be the initial action by the nurse?

Correct Answer is A

Explanation

The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

Which statement, if made by an older client diagnosed with urinary incontinence, indicates a need for further teaching?

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A nurse finds a client who is awaiting the results of diagnostic tests sitting in bed crying. Which response by the nurse would best facilitate communication?

A nurse is teaching a client about the benefits of exercise. The nurse knows teaching has been effective when the client lists which of the following health benefits of exercise? (Select all that apply).

A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?