A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).
Encourage high-fiber food choices.
Increase fluid intake to 2,000 mL per day.
Encourage ambulation several times per day.
Administer antacids as necessary per bowel management program.
Correct Answer : A,B,C
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.
Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.
They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.
Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The popliteal artery is a major blood vessel that runs behind the knee and supplies blood to the lower leg. Sitting with knees crossed can compress this artery and reduce blood flow to the leg.
This can cause numbness, tingling, or pain in the leg. It can also increase the risk of blood clots or varicose veins.
Choice A is wrong because sitting with knees crossed does not decrease the risk of skin breakdown behind the knee. In fact, it may increase the risk by causing friction or pressure on the skin.
Choice B is wrong because sitting with knees crossed does not eliminate the pain of arthritis in the lower legs.
Arthritis is a joint inflammation that causes pain, stiffness, and swelling. Sitting with knees crossed can worsen these symptoms by putting more stress on the knee joints.
Choice D is wrong because sitting with knees crossed does not avoid irritation of the knee joints.
On the contrary, it can cause irritation by overstretching the knee ligaments and muscles
Correct Answer is D
Explanation
Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.
Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.
Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.
A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.
Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.
Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.
A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.
Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.
Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.
A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.
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