Which outcome is expected for a client who has a diagnosis of constipation? The client:.
Takes a laxative daily.
Has a return to their normal bowel habits.
Requests a bedpan every four hours.
Has a bowel movement within 72 hours.
The Correct Answer is B
This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.
Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.
Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.
Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
Correct Answer is D
Explanation
Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.
Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.
This prevents the person from getting entangled or injured by the restraints.
Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.
Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.
Normal ranges for restraints are:
- Check the person at least every 15 minutes
- Remove restraints and meet basic needs at least every 2 hours
- Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist
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