Six days following a minor vehicle crash, an older client returns to the emergency department to have stitches removed. While the nurse is removing the stitches, the client reports feeling bloated and not having a bowel movement since the accident. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Perform a digital examination for fecal impaction.

Assess type and frequency of physical activities.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Fetal growth and gestational age. Ultrasound during pregnancy is commonly used to assess fetal growth, development, and gestational age. It allows healthcare providers to monitor the health and progress of the pregnancy, as well as detect any potential issues or abnormalities.

B. Lecithin-sphingomyelin ratio. This ratio is typically assessed in amniotic fluid samples to predict fetal lung maturity, but it's not the primary reason for a routine ultrasound during pregnancy.

C. Chromosomal abnormalities. While some prenatal screening tests, such as nuchal translucency ultrasound or cell-free DNA testing, can help assess the risk of chromosomal abnormalities, a routine ultrasound is not primarily conducted for this purpose.

D. Sex and size of the infant. While ultrasound can reveal the sex of the baby and provide estimates of fetal size, these are secondary to the primary goal of assessing fetal growth and gestational age.

A. Assess subconjunctival color for pallor B. Review serum creatinine results. C. No additional assessment needed. D. Obtain every 2-hour blood pressure readings.

Correct Answer is C

Explanation

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

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Naxlex Comprehensive Predictor Exams

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

Correct Answer is A

Explanation

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Correct Answer is C

Explanation

Which assessment finding of an older adult client should the nurse associate with normal aging?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?