The nurse is performing an assessment and finds that the client has nontarry and black stool. Which of the following subjective data should the nurse document as a normal finding consistent with nontarry black stool?
client reports taking iron supplement
client has dry heaves
client reports eating red meat prior to assessment
client report loss of appetite
The Correct Answer is A
Choice A rationale: Taking an iron supplement can lead to nontarry and black stool due to the dark color of iron.
Choice B rationale: Dry heaves are not typically associated with nontarry black stool. Choice C rationale: Eating red meat would result in reddish stool, not black. Choice D rationale: Loss of appetite is not directly related to the appearance of stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Observing for facial symmetry is more relevant to Cranial Nerve VII (facial nerve).
Choice B rationale: Cranial nerve III (oculomotor nerve) is responsible for pupillary constriction. The nurse should check the pupillary response to light to assess the function of this cranial nerve.
Choice C rationale: Testing visual acuity is not specific to Cranial Nerve III but is more associated with Cranial Nerve II (optic nerve).
Choice D rationale: Eliciting the gag reflex is related to Cranial Nerve IX (glossopharyngeal nerve) and X (vagus nerve), not Cranial Nerve III.
Correct Answer is D
Explanation
Choice A rationale: A peritoneal friction rub is a grating sound caused by the movement of inflamed peritoneal surfaces and is not associated with bowel sounds.
Choice B rationale: Loud continual humming bowel sounds do not accurately describe borborygmi and are not a common term used to describe bowel sounds.
Choice C rationale: Hypoactive bowel sounds indicate decreased bowel motility and are not associated with borborygmi.
Choice D rationale: Borborygmi refers to loud, gurgling bowel sounds that are audible without the use of a stethoscope. It is a normal sound associated with the movement of gas and fluid through the intestines.
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