A nurse is gathering information from a patient who has been experiencing diarrhea for several days.
What symptoms should the nurse anticipate?
Hypothermia
Rigid abdomen
Dehydration
Decreased bowel sounds
Decreased bowel sounds
The Correct Answer is C
Choice A rationale:
Hypothermia, or abnormally low body temperature, is not typically a symptom of diarrhea. While it’s possible for a person with severe diarrhea to experience chills or feel cold, hypothermia is not a direct result of diarrhea.
Choice B rationale:
A rigid abdomen is often a sign of a serious condition like peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen), but it is not typically associated with diarrhea.
Choice C rationale:
Dehydration is a common complication of diarrhea. When a person has diarrhea, they can lose a lot of fluid and electrolytes quickly, leading to dehydration. Symptoms of dehydration can include thirst, less frequent urination, dark-colored urine, fatigue, dizziness, and confusion.
Choice D rationale:
Decreased bowel sounds are not typically associated with diarrhea. In fact, bowel sounds may actually increase in some cases of diarrhea due to increased gut motility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,C,A,D
Explanation
B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.
C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.
A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.
D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.
Correct Answer is B
Explanation
Choice A rationale:
Requesting a prescription for a stool softener from the provider could be a potential solution, but it’s not the first step. Medications should be considered when lifestyle modifications and dietary changes are not effective.
Choice B rationale:
Incorporating more fluids and fiber into the patient’s diet is the most appropriate action. Constipation in older adults can be caused by dehydration and not eating enough. Dietary fiber adds bulk to the diet and is capable of absorbing water, which helps to soften the stool and promote regular bowel movements. Therefore, increasing fluid and fiber intake is often the first step in managing constipation.
Choice C rationale:
Encouraging the patient to engage in active range-of-motion exercises might not directly alleviate constipation. While physical activity is generally beneficial for overall health, increased exercise does not improve symptoms of constipation in nursing home residents or older adults.
Choice D rationale:
Advising the patient to avoid foods that cause gas might help if the patient has bloating or gas, but it won’t necessarily address the issue of constipation. The focus should be on increasing fiber and fluid intake.
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