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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 A

Explanation

The correct answer is choice A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.

A. Air pads wrap around your arms and are connected to a vacuum which improves blood flow. B. These are elastic stockings that apply pressure to the legs and increase the velocity of blood flow. C. SCDs are only worn during amputation to provide support and prevent pooling of blood in the legs. D. The device fills with air that applies intermittent or sequential pressure to the legs to enhance blood flow and venous return.

Correct Answer is D

Explanation

The correct answer is choice D. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.

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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 nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

Correct Answer is A

Explanation

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

Correct Answer is D

Explanation

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

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Which technique should the nurse use to assess the pupillary reaction on a client?

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

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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?

A patient has an order for Normal Saline 1000 mL to infuse over 3 hours. The medication will be infused with an IV pump. How many mL/h should the IV pump be programmed for?

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.