A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?
Dysrhythmias
Dilated pupils
Gastric ulcer
Diarrhea
The Correct Answer is A
A) Dysrhythmias:
Straining while defecating can trigger the Valsalva maneuver, which involves taking a deep breath and bearing down. This can lead to increased intrathoracic pressure, decreased venous return to the heart, and subsequently a sudden drop in blood pressure when the strain is released. These changes can cause cardiac dysrhythmias, particularly in older adults or those with underlying heart conditions.
B) Dilated pupils:
Dilated pupils are not a known consequence of straining while defecating. Pupillary dilation is typically associated with responses to low light, certain medications, or neurological conditions, rather than gastrointestinal strain.
C) Gastric ulcer:
Gastric ulcers are caused by factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive stomach acid. Straining during defecation does not contribute to the development of gastric ulcers.
D) Diarrhea:
Straining while defecating is more likely to be associated with constipation rather than diarrhea. Diarrhea involves frequent, loose, or watery stools, whereas straining typically occurs due to hard stools and difficulty passing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Localized edema:
Localized edema, especially when accompanied by erythema (redness), warmth, and tenderness, can be indicative of an infection in a client with diabetes mellitus. Infections in diabetic patients, particularly those affecting the feet, can lead to localized inflammation and swelling.
B. An increase in RBCs:
An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.
C. Bradycardia:
Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.
D. An increase in platelets:
An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.
E. An increase in neutrophils:
An increase in neutrophils, known as neutrophilia, is a common response to infection. Neutrophils are a type of white blood cell involved in the body's immune response to bacterial infections. In diabetic clients with foot pain, an elevated neutrophil count may suggest the presence of an infection, as the body mobilizes these cells to combat the invading pathogens.
Correct Answer is ["A","C","E"]
Explanation
A. A client who has stage IV breast cancer and is expected to live 3 months:
This client is eligible for hospice care because they have a terminal illness (stage IV breast cancer) with a prognosis of less than six months to live if the disease follows its typical course. Hospice care focuses on comfort and quality of life in the final months of life.
B. A client who has a diagnosis of COPD and requires supplemental oxygen:
This client is not automatically eligible for hospice care based solely on a COPD diagnosis and the need for supplemental oxygen. Eligibility for hospice would require a prognosis of six months or less to live if the disease follows its usual course. More specific criteria, such as frequent hospitalizations or a significant decline in functional status, would need to be met.
C. A client who has end-stage kidney disease and has stopped dialysis:
This client is eligible for hospice care because stopping dialysis typically indicates that the client has a limited life expectancy, usually measured in weeks to months. Hospice care can help manage symptoms and provide support for end-of-life care.
D. A client who has type 1 diabetes mellitus and is on an insulin pump:
This client is not eligible for hospice care based solely on the presence of type 1 diabetes mellitus and the use of an insulin pump. Hospice care eligibility is generally for clients with a terminal diagnosis and a life expectancy of six months or less if the disease follows its usual course.
E. A client who has terminal lung cancer and has discontinued all treatment:
This client is eligible for hospice care because they have a terminal illness (lung cancer) and have chosen to discontinue curative treatment. Hospice care focuses on palliative treatment to improve the quality of life and manage symptoms during the end-of-life stage.
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