A nurse is providing education for an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables.

Limit activity.

Drink four to five glasses of water daily.

Bear down hard when defecating.

Answer and Explanation

The Correct Answer is C

Choice A rationale: While dietary fiber is important for bowel health, raw vegetables can be harder to digest. Cooking or steaming vegetables may be a more suitable option for some individuals with constipation.
Choice B rationale: Limiting activity can contribute to constipation, as physical activity helps stimulate bowel movements.
Choice C rationale: Drinking four to five glasses of water daily is important for maintaining hydration and supporting normal bowel function. Dehydration can contribute to constipation.
Choice D rationale: Bearing down hard when defecating may increase the risk of complications and is not a recommended strategy for relieving constipation.

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Correct Answer is B

Explanation

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

A. A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history B. A client 45 years of age who has paraplegia C. A client 68 years of age who is comatose due to a traumatic brain injury D. A client 75 years of age who uses a cane and has dementia

Correct Answer is A

Explanation

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

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A nurse is providing education for an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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