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

Determine the client's usual bowel patern

Encourage the client to ambulate more frequently

Recommend increasing high-fiber foods daily

Answer and Explanation

The Correct Answer is B

A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may aﬀect the client's bowel function.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or eﬀective.

Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.

Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.

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Correct Answer is A

Explanation

Choice A rationale:

The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.

Choice B rationale:

Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.

Choice C rationale:

The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.

Choice D rationale:

While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.

A. Tenderness. B. Musical and drumlike. C. Absent sounds. D. Pain.

Correct Answer is B

Explanation

Choice A rationale:

Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.

Choice B rationale:

Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.

Choice C rationale:

Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.

Choice D rationale:

Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.

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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?

Nursing Test Bank

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