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 B
Explanation
The correct answer is choiceB. Remove the warm compress.
Choice A rationale:
Turning the lights on in the room would likely exacerbate the resident’s photophobia (sensitivity to light), causing more discomfort.Photophobia is a common symptom of bacterial conjunctivitis, and keeping the room dim can help alleviate this discomfort.
Choice B rationale:
Removing the warm compress is the correct action. Warm compresses can sometimes be used to relieve symptoms of conjunctivitis, but they are generally more appropriate for viral or allergic conjunctivitis.In the case of bacterial conjunctivitis, warm compresses can potentially worsen the infection by providing a warm, moist environment that promotes bacterial growth.Instead, a cool compress is often recommended to reduce inflammation and discomfort.
Choice C rationale:
Elevating the head of the bed can help reduce swelling and promote drainage, but it is not directly related to the immediate relief of eye pain and photophobia in bacterial conjunctivitis.This action might be more relevant for conditions involving fluid retention or respiratory issues.
Choice D rationale:
Offering an oral analgesic could help manage the resident’s pain, but it does not address the underlying issue of the warm compress potentially worsening the bacterial infection.Pain management is important, but it should be combined with appropriate measures to treat the infection and alleviate symptoms.
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
A. High school boys are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.
B. High school girls are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.
C. Middle school boys are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.
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