The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

Current prescribed and over-the-counter medications.

Next scheduled visit with healthcare provider.

Methods currently used to treat constipation.

Daily food and fluid intake.

Level of physical activity and exercise.

Answer and Explanation

Correct Answer : A,C,D,E

Certain medications can contribute to constipation as a side effect. Reviewing the client's medication list will help identify any potential medications that may be causing or exacerbating constipation.

Understanding the client's current approach to managing constipation, such as dietary changes, laxative use, or other remedies, will provide insight into their self-care practices and effectiveness of current interventions.

Diet plays a crucial role in bowel regularity. Assessing the client's dietary habits, including fiber intake and hydration, can help identify potential factors contributing to constipation.

Physical activity and exercise promote bowel regularity by stimulating intestinal motility. Evaluating the client's level of physical activity and exercise routine can provide information on their overall mobility and potential impact on bowel function.

The next scheduled visit with the healthcare provider may be important for the overall management of the client's health but may not be directly related to formulating a plan of care specifically for constipation.

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Correct Answer is C

Explanation

It is important to determine if the client has any plans or intentions to act upon the voices' instructions. This information helps gauge the level of risk and guides further interventions and safety measures.

While the other questions may also be important to ask during the assessment, determining if the client believes the voices are real and when the voices began can provide valuable information about the client's perception and the duration of the symptoms. Asking about the use of hallucinogens is relevant to identify potential substance-induced causes of the hallucinations. However, assessing the client's intent and potential for harm is the priority in this situation.

A. Give the client a schedule of planned daily activities. B. Engage the client in a game of cards. C. Encourage the client to have lunch off the unit. D. Complete an assessment of social support.

Correct Answer is A

Explanation

A) Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B) Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C) Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D) Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.

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The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

Correct Answer is C

Explanation

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Correct Answer is A

Explanation

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