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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F"]
Explanation
Choice A rationale:
Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.
Choice B rationale:
Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.
Choice C rationale:
Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.
Choice D rationale:
Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.
Choice E rationale:
Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.
Choice F rationale:
Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.
Correct Answer is B
Explanation
Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.