Six days following a minor vehicle crash, an older client returns to the emergency department to have stitches removed. While the nurse is removing the stitches, the client reports feeling bloated and not having a bowel movement since the accident. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Perform a digital examination for fecal impaction.

Assess type and frequency of physical activities.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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Correct Answer is D

Explanation

A. Triceps skin fold and mid-arm circumference. These measurements can provide some indication of nutritional status, but they may not be as reliable in older adults due to changes in body composition and skin elasticity.

B. Twenty-four-hour food recall, preferences, and allergies. While dietary information is important, it may not accurately reflect the client's current nutritional status.

C. Weight loss history and body surface area (BSA). While weight loss history is relevant, BSA is not typically used to assess nutritional status.

D. Body mass index (BMI) and serum albumin level. BMI is a commonly used indicator of nutritional status, and serum albumin level reflects protein status, which is important for assessing malnutrition.

A. Ask questions in a vague, nonspecific format. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions won't elicit clear answers.

B. Share personal values to put the client at ease: While building rapport is important, sharing personal values might not be necessary.

C. Get the most difficult questions over with first: This can make the client defensive and less likely to be honest.

D. Begin with less sensitive questions: Starting with general questions about lifestyle habits and then gradually transitioning to more specific questions about alcohol and substance use can create a more comfortable environment for open communication

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting an older adult client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is D

Explanation

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

Correct Answer is D

Explanation

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

An adolescent's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?