Which of the following patients should the nurse consider as having a higher risk for malnutrition?

Choice A rationale
A stool guaiac test is a simple check to find blood in your stool. It involves smearing a tiny amount of your stool on a special card, which is then tested for hidden blood. This test helps detect problems like bleeding ulcers or colon cancer in an early stage when they might not show other symptoms. The stool guaiac test looks for hidden (occult) blood in a stool sample. It can find blood even if you cannot see it yourself. It is a common type of fecal occult blood test (FOBT). Guaiac is a substance from a plant that is used to coat the FOBT test cards to make them able to detect blood.
Choice B rationale
Steatorrhea refers to the presence of excess fat in the stool. While this can be a symptom of various digestive disorders, it is not what a stool guaiac test is designed to detect. The primary purpose of a stool guaiac test is to identify hidden blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
Choice C rationale
While bacteria can be present in the stool and certain tests are designed to detect them, a stool guaiac test is not one of these. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool. The presence of blood can indicate a variety of conditions, including gastrointestinal bleeding or colon cancer.
Choice D rationale
Yeast can be present in the stool, and certain tests can detect it. However, a stool guaiac test is not designed to detect yeast. The primary purpose of a stool guaiac test is to identify hidden

blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.