The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)
Current prescribed and over-the-counter medications.
Next scheduled visit with healthcare provider.
Methods currently used to treat constipation.
Daily food and fluid intake.
Level of physical activity and exercise.
Correct Answer : A,C,D,E
Certain medications can contribute to constipation as a side effect. Reviewing the client's medication list will help identify any potential medications that may be causing or exacerbating constipation.
Understanding the client's current approach to managing constipation, such as dietary changes, laxative use, or other remedies, will provide insight into their self-care practices and effectiveness of current interventions.
Diet plays a crucial role in bowel regularity. Assessing the client's dietary habits, including fiber intake and hydration, can help identify potential factors contributing to constipation.
Physical activity and exercise promote bowel regularity by stimulating intestinal motility. Evaluating the client's level of physical activity and exercise routine can provide information on their overall mobility and potential impact on bowel function.
The next scheduled visit with the healthcare provider may be important for the overall management of the client's health but may not be directly related to formulating a plan of care specifically for constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer ischoice A.
Choice A rationale:
Having the client vocalize the instructions provided ensures that they have understood the information correctly.This method allows the nurse to confirm comprehension and clarify any misunderstandings.
Choice B rationale:
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions.It is a good supplementary measure but should not be the sole method of communication.
Choice C rationale:
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments.However, it does not guarantee that the client has understood the instructions.
Choice D rationale:
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
Correct Answer is A
Explanation
Allen's test is a procedure used to assess the patency of the ulnar artery and the collateral circulation of the hand. It is performed to determine the adequacy of collateral circulation before obtaining arterial blood gases from the radial artery. The test helps ensure that the ulnar artery is functioning properly and can supply blood to the hand if the radial artery is used for blood sampling or other invasive procedures.
The test involves occluding both the ulnar and radial arteries while the patient clenches their fist. The nurse then releases pressure on the ulnar artery while maintaining occlusion of the radial artery. The hand should quickly regain normal coloration, indicating adequate collateral circulation.
It's important to note that the Allen's test is specific to the assessment of collateral circulation in the hand and is not used for other purposes such as assessing deep vein thrombosis, cardiac output calculation, or obtaining pulmonary artery pressures.
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