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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Kyphosis: A rounding of the upper back, causing a hunchback appearance. While it can also be caused by other conditions, a mild kyphosis is a common finding in older adults due to weakening muscles and spinal compression.

B. Barrel chest: This refers to a chest that is fixed in an outward position, often caused by chronic obstructive pulmonary disease (COPD) or other lung conditions.

C. Lordosis: An exaggerated inward curve of the lower back, which is not a typical feature of normal aging.

D. Pectus excavatum: A sunken appearance of the chest wall, usually a congenital condition present from birth.

A. Tell the client the medication needs more time to work. B. Reassess the client and the level of pain. C. Ask the unlicensed assistive personnel (UAP) to offer a backrub to the client. D. Encourage the client to focus on taking deep breaths.

Correct Answer is B

Explanation

A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.

B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.

C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.

D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

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?

During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Which method is best for the nurse to use in determining early development of ascites?