When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago.”. Which action should the PN implement first?
Administer a prescribed PRN stool softener.
Encourage client to ambulate more frequently.
Recommend increasing high fiber foods daily.
Determine the client's usual bowel pattern.
The Correct Answer is D
Determine the client's usual bowel pattern.
Choice A rationale:
Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.
Choice B rationale:
Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.
Choice C rationale:
Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.
Choice D rationale:
Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"I realize that my life must go on, but sometimes I wonder why.”
Choice A rationale:
This statement may indicate frustration with physical limitations, which is common in older adults, especially after surgery. It does not necessarily indicate a need for bereavement counseling.
Choice B rationale:
Difficulty remembering simple things can be attributed to normal aging processes or other factors not directly related to bereavement.
Choice C rationale:
Expressing a sense of wondering "why”. after the loss of a spouse suggests ongoing grief and a potential need for bereavement counseling to process feelings and find meaning in life after the loss.
Choice D rationale:
Depending on children who live close-by is a common support mechanism for older adults and does not directly indicate a need for bereavement counseling.
Correct Answer is A
Explanation
The injury description by the mother varies from the child's version.
Choice A rationale:
The practical nurse (PN) should note the significant indicator of possible child abuse, which is the discrepancy between the mother's description of the injury and the child's version. In cases of child abuse, perpetrators often provide inconsistent or conflicting explanations about how the injuries occurred, raising suspicion of maltreatment. This inconsistency can be a red flag for the PN to further assess the situation and, if necessary, report concerns to the appropriate authorities.
Choice B rationale:
While the child looking at the floor when answering questions might be a behavior worth noting, it alone is not a definitive indicator of child abuse. Children may exhibit various emotional responses for various reasons, and it requires further assessment to determine if there are signs of abuse.
Choice C rationale:
The healing of abrasions on the child's arms, legs, and chest does not necessarily indicate child abuse. Children are active and prone to minor injuries, which are a normal part of growing up. The PN should investigate further to determine the cause of the injuries.
Choice D rationale:
The mother describing in detail what she did for her injured child does not automatically suggest child abuse. It is essential for the PN to gather more information and conduct a comprehensive assessment before drawing any conclusions.
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