The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?
Client reports taking an iron supplement
Client has dry heaves
The client reports eating red meat prior to the assessment
Client reports loss of appetite
The Correct Answer is C
A. Iron supplements typically lead to darker stools but may not necessarily present as a non-tarry black stool.
B. Dry heaves or vomiting could potentially indicate upper gastrointestinal bleeding but not specifically correlate with non-tarry black stool.
C. Consuming red meat can cause black stools due to its breakdown products, which is a normal finding.
D. Loss of appetite doesn't directly relate to stool color or consistency.
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Related Questions
Correct Answer is D
Explanation
A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.
Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.
C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.
Correct Answer is ["A"]
Explanation
A. Abdominal distention can occur due to gas accumulation from undigested lactose.
B. Visible peristalsis is not typically a specific clinical finding associated with lactose intolerance.
C. Hypoactive bowel sounds are not commonly associated with lactose intolerance.
D. Occasional diarrhea is a common symptom due to the inability to digest lactose properly.
E. Flatus or excessive gas production is a common symptom due to the fermentation of undigested lactose by intestinal bacteria.
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