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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.
Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.
Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.
Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.
Correct Answer is C
Explanation
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
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