A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility.
Which of the following interventions should the nurse include in the plan?
Encourage fluid intake of at least 2 L/day.
Provide a low-fiber diet.
Administer a stimulant laxative daily.
Discourage physical activity.
The Correct Answer is A
Encourage fluid intake of at least 2 L/day.
This is because adequate hydration can help soften the stool and facilitate its passage through the intestines. Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.
Choice B is wrong because a low-fiber diet can contribute to constipation by reducing the bulk and water content of the stool.
Fiber helps retain water in the stool and stimulate peristalsis. A high-fiber diet is recommended for clients who have constipation.
Choice C is wrong because a stimulant laxative should not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa. Stimulant laxatives should be used only as a last resort when other measures fail.
Choice D is wrong because physical activity can help prevent constipation by increasing intestinal motility and blood flow. Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.
Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate. Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Diphenhydramine.Diphenhydramine is an antihistamine and sedative medication that can causedeliriumin older adults, especially when used in high doses or for a long time.Delirium is a serious change in mental abilities that results in confused thinking and reduced awareness of the surroundings.It can be caused by various factors, such as infections, medications, surgery, or alcohol or drug use or withdrawal.Delirium can have serious consequences, such as increased risk of falls, complications, and death.
Choice A is wrong because acetaminophen is a pain reliever and fever reducer that does not usually cause delirium in older adults.
However, acetaminophen overdose can cause liver damage and altered mental status.
Choice C is wrong because metformin is an oral medication that lowers blood sugar levels in people with type 2 diabetes.
Metformin does not typically cause delirium in older adults.
However, metformin can cause a rare but serious condition called lactic acidosis, which can cause confusion and other symptoms.
Choice D is wrong because lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure and prevents heart failure.
Lisinopril does not usually cause delirium in older adults.
However, lisinopril can cause a rare but serious condition called angioedema, which can cause swelling of the face, tongue, or throat and difficulty breathing.
Normal ranges for some relevant laboratory tests are:.
• Albumin: 3.5-5.0 g/dL.
• Potassium: 3.5-5.0 mEq/L.
• Total cholesterol: <200 mg/dL.
• Hemoglobin: 13.5-17.5 g/dL for men; 12.0-15.5 g/dL for women.
Correct Answer is ["A","B","C","D","E"]
Explanation
The correct answer isA, B, C, D, and E.
All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work.A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery.The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.
• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.
• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.
• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.
• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.
• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.
A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people.The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health.Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.
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