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 A

Explanation

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

A. The site where the blood pressure was obtained. B. Interventions implemented in response to a client's blood pressure. C. A client's position when the blood pressure was obtained. D. The frequency in which a blood pressure is taken. E. A client's response to interventions implemented.

Correct Answer is ["A","B","C","D","E"]

Explanation

A. The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B. Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C. A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D. The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E. A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

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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 caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

Correct Answer is ["A","B","C","D","E"]

Explanation

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

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A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?

A nurse is unable to palpate a client's dorsalis pedis pulse. The nurse will next attempt to palpate the

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that

A nurse is assisting with teaching a newly licensed nurse about the loss of body heat. The nurse should include that heat loss that occurs when sweat dries on the skin is caused by which of the following mechanisms?

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