A nurse is providing care for an elderly patient who is experiencing constipation.
What action should the nurse take?
Request a prescription for a stool softener from the provider.
Incorporate more fluids and fiber into the patient’s diet.
Encourage the patient to engage in active range-of-motion exercises.
Advise the patient to avoid foods that cause gas.
None
None
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Numbness in the fingers is not typically a symptom of respiratory acidosis. This condition is characterized by an excess of carbon dioxide (CO2) in the body, which leads to a decrease in the pH of your blood, making it too acidic. Numbness in the fingers could be a symptom of other conditions, such as peripheral neuropathy or Raynaud’s disease.
Choice B rationale:
Abdominal pain is also not a common symptom of respiratory acidosis. While abdominal discomfort can occur in a variety of conditions, it is not directly associated with the acid-base balance disturbance that characterizes respiratory acidosis.
Conditions that commonly cause abdominal pain include gastrointestinal issues like gastritis, appendicitis, or gallstones.
Choice C rationale:
Dry skin is not a symptom of respiratory acidosis. The skin’s condition can be influenced by many factors, including hydration, environmental conditions, and certain skin conditions like eczema or psoriasis. Respiratory acidosis, on the other hand, is a condition that affects the acid-base balance in the body due to alveolar hypoventilation.
Choice D rationale:
Lethargy is indeed a symptom of respiratory acidosis. This condition occurs when the lungs can’t remove enough CO2, leading to an increase in the acidity of the blood. Symptoms of respiratory acidosis vary according to how long you’ve had the condition and its severity. Initial symptoms can include anxiety, blurred vision, and shortness of breath. If left untreated or in severe cases, symptoms may include fatigue, lethargy, delirium, or confusion. Therefore, a nurse assessing a patient with respiratory acidosis should anticipate lethargy among other symptoms.
Correct Answer is D
Explanation
Choice A rationale:
Reflex incontinence is a type of urinary incontinence that occurs when the person has no control over urination. They’re unable to feel when their bladder is full and can’t control the process of emptying it. This is often due to a brain or spinal cord injury that disrupts communication between these organs. However, this condition does not necessarily indicate the need for catheterization in a client with paraplegia who is already on an intermittent urinary catheterization program.
Choice B rationale:
Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. This condition can be caused by various factors, including neurological disorders, bladder abnormalities, and certain medications. While it can be a challenge for individuals with paraplegia, it does not directly indicate the need for catheterization.
Choice C rationale:
Nocturnal enuresis, or bedwetting, is involuntary urination while asleep. It’s a common condition, especially in young children, but it can affect individuals of any age. In the context of a client with paraplegia, nocturnal enuresis could be a symptom of a larger issue, such as a urinary tract infection or bladder dysfunction, but it does not directly indicate the need for catheterization.
Choice D rationale:
Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.