A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

encourage the patient to drink at least 3000 ml of ﬂuid a day.

suggest that the patient increase dietary intake of foods that are high in fiber.

inform the patient that a daily bowel movement is not necessary.

perform a focused nursing assessment to identify risk factors for constipation.

Answer and Explanation

The Correct Answer is D

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

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Correct Answer is A

Explanation

Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.

Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inﬂammation in the gastrointestinal tract, evaluating intake and output can help to identify any ﬂuid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.

A. I should weigh myself daily and report any sudden weight loss or gain." B. I need to limit my ﬂuid intake to no more than 1 quart of liquids a day," C. I will eat foods high in potassium because the diuretics cause potassium loss.” D. I need to shop for foods that are low in sodium and avoid adding salt to foods.

Correct Answer is C

Explanation

The correct answer is c. I will eat foods high in potassium because the diuretics cause potassium loss.

Rationale for Choice A:

Statement:"I should weigh myself daily and report any sudden weight loss or gain."
Rationale:This statement is correct.It's crucial for patients with SIADH to monitor their weight daily as even slight fluctuations can signal fluid imbalances.Sudden weight gain can indicate fluid retention,while sudden weight loss might suggest dehydration.Both scenarios warrant medical attention.

Rationale for Choice B:

Statement:"I need to limit my fluid intake to no more than 1 quart of liquids a day."
Rationale:This statement is also correct.Fluid restriction is a cornerstone of SIADH management.By limiting fluid intake,patients can help prevent the buildup of excess fluid in the body,which can lead to complications such as hyponatremia (low sodium levels in the blood) and edema.

Rationale for Choice C:

Statement:"I will eat foods high in potassium because the diuretics cause potassium loss."
Rationale:This statement is incorrect.While some diuretics used in the treatment of SIADH can indeed cause potassium loss,this is not a universal side effect.Furthermore,increasing potassium intake without medical supervision can be dangerous,potentially leading to hyperkalemia (high potassium levels in the blood).It's essential for patients to consult with their healthcare providers for individualized guidance on potassium intake.

Rationale for Choice D:

Statement:"I need to shop for foods that are low in sodium and avoid adding salt to foods."
Rationale:This statement is correct.A low-sodium diet is often recommended for patients with SIADH to help manage fluid balance and prevent hyponatremia.Restricting sodium intake can reduce fluid retention and help maintain appropriate sodium levels in the blood.

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A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

Correct Answer is A

Explanation

When teaching a patient with chronic SIADH about long-term management of the disorder, the nurse determines that additional instruction is needed when the patient says:

Correct Answer is C

Explanation

A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dl (3.5 mmol/L), phosphorus of 1.7 mg/dl (55 mmol/L), serum creatinine of 2.2 mg/dl (194 mmol/L). and high urine calcium. While the patient awaits surgery, the nurse should:

Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:

One of the intraoperative activities that are performed by the perioperative nurse and are specific to the circulating function is:

A nursing assessment of a patient with Cushing syndrome reveals that the patient has truncal obesity and thin and legs. An additional manifestation of Cushing syndrome that the nurse would expect to find is:

The physical environment and traffic control measures of the operating room are designed primarily to:

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?