A nurse is reinforcing teaching with a patient who reports constipation.
Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
Ignoring the urge to defecate
Increased fiber in the diet
Excessive laxative use
Increased activity
Correct Answer : A,C
The correct answers are Choices A and C.
Choice A rationale: Ignoring the urge to defecate can lead to constipation because the longer stool remains in the colon, the more water is absorbed from it, making it harder and more difficult to pass. This can lead to a cycle of further constipation and discomfort.
Choice B rationale: Increased fiber in the diet usually helps prevent constipation by adding bulk to the stool and making it easier to pass. Therefore, it is not a cause of constipation, but rather a preventive measure.
Choice C rationale: Excessive laxative use can lead to dependence on laxatives for bowel movements and can disrupt normal bowel function. Over time, this can lead to constipation as the bowel becomes less responsive to normal stimuli.
Choice D rationale: Increased activity generally helps to prevent constipation by stimulating bowel motility. Physical exercise can enhance the efficiency of the digestive system, so it is not a cause of constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.
Choice B rationale:
Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.
Choice C rationale:
Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.
Choice D rationale:
Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment
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