A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Assist the client to a left side-lying position with the right knee flexed.

Prepare the client for a chest x-ray.

Administer a cleansing enema.

Auscultate the client’s bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

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Correct Answer is A

Explanation

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

A. “Beginning at age 60, you should have a colonoscopy.”. B. “You should have a fecal occult blood test every year.”. C. “The recommendation is to have a sigmoidoscopy every 10 years.”. D. “We’ll get a blood sample from you and send it for a screening test.”.

Correct Answer is B

Explanation

Choice A rationale

While colonoscopy is a screening method for colon cancer, it is not typically recommended to begin at age 60 for individuals at average risk. Instead, colonoscopy screening is usually recommended to begin at age 50 and continue every 10 years if no polyps are found.

Choice B rationale

The recommendation for an average risk individual for colon cancer is to have a fecal occult blood test every year. This test checks for hidden blood in the stool, which can be an early sign of cancer.

Choice C rationale

Sigmoidoscopy every 10 years is another screening option for colon cancer. However, it only examines the rectum and lower third of the colon, whereas a colonoscopy examines the entire colon.

Choice D rationale

Blood tests are not typically used as a primary screening method for colon cancer. They may be used in conjunction with other tests, but a blood sample alone is not sufficient for screening.

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A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Correct Answer is A

Explanation

A nurse in a clinic is caring for a middle-aged patient who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening.What does that involve?” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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