A patient's admission assessment includes pertinent information about bowel elimination.
Which subjective information collected by the nurse will be documented?
Shape of abdomen
Bowel sounds
Abdominal cramping and discomfort
Distention of abdomen
The Correct Answer is C
Choice A The shape of the abdomen is a physical assessment finding and not subjective
information provided by the patient. It involves the nurse's observation of the patient's abdomen during the examination.
Choice B Bowel sounds are also physical assessment findings that involve the nurse listening to the patient's abdomen using a stethoscope.
Choice C This is the correct answer. Abdominal cramping and discomfort are subjective symptoms reported by the patient and are relevant to the patient's bowel elimination status. Choice D Like the shape of the abdomen, the distention of the abdomen is a physical assessment finding and not subjective information provided by the patient.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Laxatives might be an option, but they should not be the first intervention. Other noninvasive measures should be tried first.
Choice B Administering a cleansing enema is not the first intervention for a patient having
trouble defecating into a bedpan. It is an invasive procedure and should be considered after less invasive measures have been tried.
Choice C Withholding pain medication might lead to unnecessary discomfort for the patient and is not the best approach to promote bowel movements.
Choice D Raising the head of the bed will help the patient assume a more upright position, which can facilitate bowel movement and defecation into the bedpan more effectively.
Correct Answer is B
Explanation
The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Choice A rationale:
Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.
Choice B rationale:
Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.
Choice C rationale:
Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.
Choice D rationale:
Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.
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