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","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.

A. Reassure the client that someone will check on him hourly. B. Place fresh water and a glass within reach on the bedside table. C. Ensure that the call bell is easily accessible to the client. D. Offer the client an evening snack before providing oral care.

Correct Answer is C

Explanation

The correct answer is choice C: Ensure that the call bell is easily accessible to the client.

Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.

Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.

Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.

Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.

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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

Naxlex Comprehensive Predictor Exams

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Correct Answer is ["A","C","F"]

Explanation

When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

Correct Answer is C

Explanation

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