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 D

Explanation

Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.

Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.

A. Presence of pedal pulses and intact sensation B. Presence of fingernail clubbing C. Presence of abdominal rebound tenderness D. Presence of any petechiae or bruises

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because presence of pedal pulses and intact sensation is the most important bath time assessment of the diabetic patient. Pedal pulses are the pulses that can be felt on the top or side of the foot, and they indicate the blood flow to the lower extremities. Intact sensation is the ability to feel touch, pain, temperature, and vibration on the skin, and it indicates the nerve function of the lower extremities. Diabetic patients are at risk of developing peripheral vascular disease and peripheral neuropathy, which can impair the blood flow and nerve function of the lower extremities, and lead to ulcers, infections, or amputations. The nurse should assess the pedal pulses and intact sensation of the diabetic patient regularly, especially before and after bathing, to monitor for any signs of complications or deterioration.

Choice B reason: This is an incorrect choice because presence of fingernail clubbing is not the most important bath time assessment of the diabetic patient. Fingernail clubbing is a condition where the nails become curved and enlarged, and the nail bed becomes soft and spongy. It is a sign of chronic hypoxia or low oxygen levels in the blood, and it can be associated with various diseases such as lung cancer, cystic fibrosis, or congenital heart defects. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice C reason: This is an incorrect choice because presence of abdominal rebound tenderness is not the most important bath time assessment of the diabetic patient. Abdominal rebound tenderness is a sign of peritoneal inflammation, which is the inflammation of the membrane that lines the abdominal cavity and organs. It is elicited by pressing and releasing the abdomen quickly, and it causes pain when the pressure is released. It can be caused by various conditions such as appendicitis, diverticulitis, or peritonitis. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice D reason: This is an incorrect choice because presence of any petechiae or bruises is not the most important bath time assessment of the diabetic patient. Petechiae are small, red, or purple spots on the skin that are caused by bleeding under the skin. Bruises are larger, blue, or purple areas on the skin that are caused by bleeding under the skin. They can be caused by various factors such as trauma, infection, medication, or blood disorders. However, they are not a common or specific complication of diabetes, and they do not pose an immediate risk of harm or injury to the diabetic patient.

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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 is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

Correct Answer is D

Explanation

Which bath time assessment of the diabetic patient is most important?

Correct Answer is A

Explanation

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