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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 B

Explanation

A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.

B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.

C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.

D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.

A. Vitamins B. Lipids C. Protein D. Carbohydrates

Correct Answer is C

Explanation

The correct answer is choice C. Protein is most important for wound healing. After abdominal surgery, the client requires adequate protein to promote wound healing and tissue repair. Protein is essential for collagen synthesis, a protein that is responsible for the tensile strength of the wound. The recommended daily allowance for protein for an adult is 0.8 g/kg of body weight. Foods high in protein include meat, fish, poultry, dairy products, beans, and nuts.

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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

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Correct Answer is B

Explanation

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Correct Answer is C

Explanation

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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.