A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Ignoring the urge to defecate

Increased activity

Excessive laxative use

Increased fiber in the diet

Inadequate fluid intake

Answer and Explanation

Correct Answer : A,C,E

A. Ignoring the urge to defecate: Ignoring the urge allows stool to remain in the colon longer, leading to harder stools and constipation.

B. Increased activity: Increased activity promotes bowel motility and helps prevent constipation.

C. Excessive laxative use: Chronic use can lead to dependence and reduced natural bowel motility, contributing to constipation.

D. Increased fiber in the diet: Increased fiber typically alleviates constipation unless fluid intake is inadequate.

E. Inadequate fluid intake: Insufficient fluids lead to harder stools and decreased bowel motility, causing constipation.

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Correct Answer is A

Explanation

A. Reflex incontinence: Reflex incontinence occurs due to involuntary bladder contractions from nerve damage, such as after a spinal cord injury. The bladder empties without the client’s control.

B. Stress incontinence: Stress incontinence involves leakage caused by increased abdominal pressure (e.g., sneezing or laughing) and is unrelated to nerve damage.

C. Urge incontinence: Urge incontinence is characterized by a sudden, intense need to urinate, which is not typically seen with spinal cord injury-related nerve damage.

D. Overflow incontinence: Overflow incontinence results from incomplete bladder emptying, often due to obstruction or weakened bladder muscles, not reflexes from nerve damage.

A. Respiratory rate 28/min B. Pink mucous membranes. C. Restlessness D. Heart rate 110/min

Correct Answer is B

Explanation

A. Respiratory rate 28/min: A high respiratory rate suggests ongoing respiratory distress and that the intervention has not yet been effective.

B. Pink mucous membranes: Pink mucous membranes indicate adequate oxygenation and improved perfusion, showing that supplemental oxygen is effective.

C. Restlessness: Restlessness is a sign of hypoxia and indicates the oxygen therapy is not sufficient.

D. Heart rate 110/min: Tachycardia often occurs with hypoxia and does not indicate effective oxygen therapy.

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A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?

Correct Answer is B

Explanation

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