During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation.

Aging patients always have difficulty having a bowel movement while hospitalized

Elderly patients almost always abuse laxatives, which creates problems with constipation.

In elderly patients, the rectal sphincter has lost elasticity, which decreases the sensation of urgency.

Answer and Explanation

The Correct Answer is A

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

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Correct Answer is D

Explanation

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

A. Request assistance from a second nurse. B. Count the client's apical pulse. C. Check the client's pulse rate for 1 min. D. Calculate the difference between the client's peripheral pulse and the client's apical pulse.

Correct Answer is A

Explanation

A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.

C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.

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During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

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