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The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem.
Which assessment cues would support constipation? Select all that apply.

Stool is hard and has a consistency of small marbles.

Bowel sounds are hyperactive in all four quadrants.

Client reports they have not had a bowel movement for the past 4 days.

Client reports urgency when needing to have a bowel movement.

Client states they have to strain hard when having a bowel movement.

Answer and Explanation

Correct Answer : A,C,E

The correct answer is choices A, C, and E.

Stool is hard and has a consistency of small marbles is a sign of constipation.
Bowel sounds that are hyperactive in all four quadrants are an indication of diarrhea rather than constipation.
Client reports they have not had a bowel movement for the past 4 days supports the diagnosis of constipation.
Client reports urgency when needing to have a bowel movement is more indicative of diarrhea than constipation.
Client states they have to strain hard when having a bowel movement is a sign of constipation.

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Correct Answer is D

Explanation

The correct answer is choice D, Jell-O, broth, apple juice. A clear liquid diet consists of fluids and foods that are clear and liquid at room temperature. These foods are easy to digest and leave no residue in the gastrointestinal tract. Examples include water, clear fruit juices, clear broths, tea, coffee without cream, and Jell-O.

A. Nonmaleficence B. Veracity C. Fidelity D. Beneficence

Correct Answer is A

Explanation

The correct answer is choice A. By asking for a sitter to stay at the bedside to keep the client company and minimize the risk for falls, the nurse is demonstrating the ethical principle of nonmaleficence. Nonmaleficence refers to the duty to do no harm to the client, and in this case, the nurse is taking proactive steps to prevent harm to the client by ensuring their safety and well-being. Veracity (choice B) refers to the principle of truthfulness and honesty in communication, fidelity (choice C) refers to the principle of keeping promises and maintaining trust in the nurse-client relationship, and beneficence (choice D) refers to the principle of promoting good and doing what is in the best interest of the client. While all of these principles are important in nursing practice, the nurse in this scenario is primarily demonstrating nonmaleficence by taking action to prevent harm to the client.

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The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been prescribed a clear liquid diet. What food or fluids will be served?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

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A nurse is interviewing a newly admitted patient. What question would best exhibit cultural competence?

Which of the following scenarios would represent proper delegation as applies to delegating care to the right professional?

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem.
Which assessment cues would support constipation? Select all that apply.