The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?

Suggest using a stool softener.

Recommend a daily laxative.

Obtain a stool specimen.

Discuss oral analgesic options.

Answer and Explanation

The Correct Answer is A

A. Suggesting a stool softener is appropriate as it helps to ease bowel movements and reduce straining, which can alleviate pain associated with hemorrhoids and help establish a regular bowel pattern.
B. Recommending a daily laxative may not be appropriate for long-term use and could potentially exacerbate the issue if overused. It is generally better to start with less invasive measures like stool softeners.
C. Obtaining a stool specimen may be necessary for diagnostic purposes but does not directly address the immediate concern of painful defecation due to hemorrhoids.
D. Discussing oral analgesic options might help with pain management, but it does not address the underlying issue of constipation and the need for a regular bowel pattern. Stool softeners are more directly related to resolving the constipation problem.

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Correct Answer is C

Explanation

A. Removing the coffee might not be necessary if coffee is allowed on a clear liquid diet. The client may have been provided with the coffee based on dietary guidelines.
B. Determining which staff member brought the coffee does not address the immediate need to ensure dietary guidelines are followed.
C. On a clear liquid diet, coffee is typically allowed as long as it is consumed without milk or cream. Advising the client about this restriction ensures adherence to the diet and proper management of dietary restrictions.
D. Consulting with the dietician is important for confirming dietary guidelines but addressing the immediate situation with the client’s understanding of their diet is a more direct action.

A. Apply a barrier ointment to intact areas that may be exposed to moisture. B. Determine the size and depth of skin breakdown over the sacral area. C. Complete a functional assessment of the client's self-care abilities. D. Establish a toileting schedule to decrease episodes of incontinence.

Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

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The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Correct Answer is B

Explanation

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