A patient expresses concerns over having bright red stool. Which response by the nurse is most appropriate?
"Sometimes severe stress can make the stool bright red."
"This is probably nothing. Just let me know if it happens again."
"This needs to be investigated. I will need a stool sample immediately and need to notify the Charge RN."
"You should schedule a colonoscopy as soon as possible."
The Correct Answer is A
Choice A: Bright red stool can be caused by various factors, including the consumption of certain foods, medications, or gastrointestinal bleeding. Stress can lead to changes in bowel movements and might cause bright red stool due to increased gastrointestinal motility.
Choice B: While it's essential to reassure the patient, dismissing their concern without further assessment is not appropriate. The nurse should still investigate the potential causes of bright red stool.
Choice C: Jumping to conclusions and ordering immediate tests without further assessment is not the best approach. Before taking any action, the nurse should gather more information and assess other possible causes.
Choice D: Suggesting a colonoscopy as the first step is not necessary for every case of bright red stool. Further assessment is needed to determine the cause before resorting to such an invasive procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Holding the enema for only 5 minutes may not provide enough time for the mineral oil to soften the stool and facilitate a bowel movement.
Choice B Holding the enema for 60 minutes is unnecessary and can lead to discomfort and difficulty for the patient.
Choice C Holding the enema for only 1 minute is too short for the mineral oil to be effective in softening the stool.
Choice D Encouraging the patient to hold the mineral oil enema for a minimum of 15 minutes allows sufficient time for the oil to work on the stool and improve the chances of a successful bowel movement.
Correct Answer is D
Explanation
Choice A This range of bowel sounds is considered normal. Hyperactive bowel sounds refer to an increased frequency and intensity of bowel sounds, exceeding the upper limit of the normal range.
Choice B Bowel sounds less than the normal range might indicate decreased bowel motility but are not associated with hyperactive bowel sounds.
Choice C Absent bowel sounds would be concerning and may indicate an ileus or other gastrointestinal issue, but it is not associated with hyperactive bowel sounds.
Choice D Hyperactive bowel sounds are characterized by an increased frequency and intensity of bowel sounds, exceeding the normal range, and are likely to be documented in a patient with abdominal pain.
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