The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient?

Perceived constipation related to expectation of daily bowel movements.

Impaired bowel elimination related to abdominal muscle weakness.

Risk for constipation related to irregular defecation habits.

Constipation related to side effects of pain medication.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect choice because perceived constipation related to expectation of daily bowel movements is not an appropriate nursing diagnosis for this patient. Perceived constipation is a subjective problem that occurs when the patient's bowel elimination pattern does not meet their personal expectations. The patient may not have any objective signs of constipation, such as hard stools, straining, or abdominal discomfort. This diagnosis is not applicable to this patient, who has objective signs of constipation and a clear cause of the problem.

Choice B reason: This is an incorrect choice because impaired bowel elimination related to abdominal muscle weakness is not an appropriate nursing diagnosis for this patient. Impaired bowel elimination is a problem that occurs when the patient has difficulty in passing stools or has a change in bowel habits. Abdominal muscle weakness is a possible factor that can affect bowel function, but it is not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who has a normal muscle strength and a clear cause of the problem.

Choice C reason: This is an incorrect choice because risk for constipation related to irregular defecation habits is not an appropriate nursing diagnosis for this patient. Risk for constipation is a potential problem that occurs when the patient is vulnerable to developing constipation due to various factors. Irregular defecation habits are a possible factor that can increase the risk of constipation, but they are not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who already has constipation and a clear cause of the problem.

Choice D reason: This is the correct choice because constipation related to side effects of pain medication is an appropriate nursing diagnosis for this patient. Constipation is a problem that occurs when the patient has infrequent, difficult, or incomplete bowel movements. Pain medication, especially opioids, are a common cause of constipation, as they can slow down the gastrointestinal motility and reduce the stool volume and water content. This diagnosis is applicable to this patient, who has objective signs of constipation and a clear cause of the problem..

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Total urinary incontinence related to inability to feel urge to urinate is not appropriate for a patient with xerostomia. Xerostomia is the condition of having a dry mouth due to reduced or absent saliva production. It does not affect the urinary system or the sensation of bladder fullness.

Choice B reason: This is correct. Impaired oral mucous membranes related to decreased salivation and dry mouth is appropriate for a patient with xerostomia. Xerostomia can cause oral mucous membranes to become dry, cracked, inflamed, or infected. It can also affect the patient's ability to chew, swallow, speak, or taste.

Choice C reason: This is incorrect. Bathing self-care deficit related to inability to perceive left-sided body parts is not appropriate for a patient with xerostomia. Xerostomia does not affect the patient's perception of body parts or the ability to perform bathing activities.

Choice D reason: This is incorrect. Disturbed sensory perception related to feeling of electric pain in feet and hands is not appropriate for a patient with xerostomia. Xerostomia does not cause electric pain in the extremities. This symptom may be related to a nerve disorder, such as peripheral neuropathy.

A. The patient must hold on to the railing when ambulating in the hallway. B. The patient must add extra seasoning to food in order for it to have any flavor. C. The patient suffered a first-degree burn when a heating pad was left on too long. D. The patient did not smell smoke even though the smoke detector was alarming.

Correct Answer is A

Explanation

Choice A reason: This is correct. The patient must hold on to the railing when ambulating in the hallway indicates that the patient is experiencing difficulty with proprioception. Proprioception is the body's ability to sense its own position, movement, and spatial orientation. It helps the patient maintain balance and coordination. If the patient has impaired proprioception, they may feel unsteady or fall when walking without support.

Choice B reason: This is incorrect. The patient must add extra seasoning to food in order for it to have any flavor does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of taste, which can be caused by various factors, such as aging, medication, infection, or smoking. It does not affect the patient's perception of their body or movement.

Choice C reason: This is incorrect. The patient suffered a first-degree burn when a heating pad was left on too long does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of pain or temperature, which can be caused by nerve damage, diabetes, or spinal cord injury. It does not affect the patient's perception of their body or movement.

Choice D reason: This is incorrect. The patient did not smell smoke even though the smoke detector was alarming does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of smell, which can be caused by nasal congestion, allergy, infection, or head injury. It does not affect the patient's perception of their body or movement.

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The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is most appropriate for a patient with xerostomia?

Correct Answer is B

Explanation

Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

Correct Answer is A

Explanation

Which technique will provide the most accurate measurement of the patient’s core temperature?

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)?

Which action by the nurse demonstrates the concept of nurse autonomy?

Which data will the nurse categorize as objective for a patient who has just completed an assessment?

Why is acute pain particularly dangerous for a patient having a heart attack?

Which nursing care concept is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient?

Which assessment findings lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours? (Select all that apply.)