A nurse is providing care for an elderly patient who is experiencing constipation.
What action should the nurse take?
Request a prescription for a stool softener from the provider.
Incorporate more fluids and fiber into the patient’s diet.
Encourage the patient to engage in active range-of-motion exercises.
Advise the patient to avoid foods that cause gas.
The Correct Answer is B
Choice A rationale:
Requesting a prescription for a stool softener from the provider could be a potential solution, but it’s not the first step. Medications should be considered when lifestyle modifications and dietary changes are not effective.
Choice B rationale:
Incorporating more fluids and fiber into the patient’s diet is the most appropriate action. Constipation in older adults can be caused by dehydration and not eating enough. Dietary fiber adds bulk to the diet and is capable of absorbing water, which helps to soften the stool and promote regular bowel movements. Therefore, increasing fluid and fiber intake is often the first step in managing constipation.
Choice C rationale:
Encouraging the patient to engage in active range-of-motion exercises might not directly alleviate constipation. While physical activity is generally beneficial for overall health, increased exercise does not improve symptoms of constipation in nursing home residents or older adults.
Choice D rationale:
Advising the patient to avoid foods that cause gas might help if the patient has bloating or gas, but it won’t necessarily address the issue of constipation. The focus should be on increasing fiber and fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Numbness in the fingers is not typically a symptom of respiratory acidosis. This condition is characterized by an excess of carbon dioxide (CO2) in the body, which leads to a decrease in the pH of your blood, making it too acidic. Numbness in the fingers could be a symptom of other conditions, such as peripheral neuropathy or Raynaud’s disease.
Choice B rationale:
Abdominal pain is also not a common symptom of respiratory acidosis. While abdominal discomfort can occur in a variety of conditions, it is not directly associated with the acid-base balance disturbance that characterizes respiratory acidosis.
Conditions that commonly cause abdominal pain include gastrointestinal issues like gastritis, appendicitis, or gallstones.
Choice C rationale:
Dry skin is not a symptom of respiratory acidosis. The skin’s condition can be influenced by many factors, including hydration, environmental conditions, and certain skin conditions like eczema or psoriasis. Respiratory acidosis, on the other hand, is a condition that affects the acid-base balance in the body due to alveolar hypoventilation.
Choice D rationale:
Lethargy is indeed a symptom of respiratory acidosis. This condition occurs when the lungs can’t remove enough CO2, leading to an increase in the acidity of the blood. Symptoms of respiratory acidosis vary according to how long you’ve had the condition and its severity. Initial symptoms can include anxiety, blurred vision, and shortness of breath. If left untreated or in severe cases, symptoms may include fatigue, lethargy, delirium, or confusion. Therefore, a nurse assessing a patient with respiratory acidosis should anticipate lethargy among other symptoms.
Correct Answer is A
Explanation
Choice A rationale:
Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.
Choice B rationale:
Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.
Choice C rationale:
Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.
Choice D rationale:
Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.
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