The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

17-year-old who has just had an ankle cast applied.

60-year-old recovering from a heart attack.

80-year-old admitted for an infected tooth.

28-year-old new mother of twins.

Answer and Explanation

The Correct Answer is B

A. 17-year-old who has just had an ankle cast applied: While constipation may occur due to reduced mobility after having an ankle cast applied, teaching about the hazards of straining during bowel movements is not the priority for this client. The immediate concern may be related to cast care and mobility.

B. 60-year-old recovering from a heart attack: This client is recovering from a heart attack, and straining during bowel movements can increase intra-abdominal pressure and potentially lead to complications such as vagal stimulation, which may trigger arrhythmias or further stress the heart. Therefore, teaching about the hazards of straining during bowel movements is essential for this client to prevent complications and promote cardiac safety.

C. 80-year-old admitted for an infected tooth: While constipation may occur as a side effect of certain medications or due to decreased oral intake, teaching about straining during bowel movements is not the immediate priority for this client, given the primary reason for admission is an infected tooth. However, if constipation becomes a concern during the admission, it can be addressed accordingly.

D. 28-year-old new mother of twins: While postpartum mothers may experience constipation due to various factors such as changes in hormone levels, reduced mobility after delivery, and opioid use for pain management, teaching about the hazards of straining during bowel movements may not be the priority compared to other immediate postpartum care needs, such as breastfeeding support, perineal care, and newborn care.

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Correct Answer is A

Explanation

A. White blood cells (WBCs): The nurse should monitor the client's white blood cell count to assess their ability to withstand exposure to pathogens. WBCs are integral to the body's immune response, as they play a crucial role in defending against infections. An elevated or decreased WBC count can indicate an underlying infection or immune dysfunction, helping the nurse identify potential risks to the client's health. Regular monitoring of WBC levels allows for timely intervention and assessment of the client's immune status.

B. Platelets: Platelets are primarily responsible for blood clotting and are not directly involved in the body's immune response to pathogens. While they are important for hemostasis and preventing excessive bleeding, monitoring platelet count is not directly indicative of a client's ability to withstand exposure to pathogens.

C. Red blood cells: Red blood cells (RBCs) are responsible for transporting oxygen throughout the body and are not directly involved in the immune response to pathogens. Monitoring red blood cell count, hemoglobin, and hematocrit levels is important for assessing oxygen-carrying capacity and detecting conditions such as anemia, but it does not provide specific information about the client's ability to combat infections.

D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is used to assess blood volume and oxygen-carrying capacity. While changes in hematocrit levels may indirectly indicate certain health conditions, such as dehydration or polycythemia, it does not directly reflect the client's immune status or ability to withstand exposure to pathogens.

A. functional incontinence. B. a urinary tract infection. C. ketone bodies in the urine. D. nocturia.

Correct Answer is B

Explanation

A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments. Cloudy, amber urine with an unpleasant odor is not indicative of functional incontinence.

B. Urinary tract infection (UTI): Cloudy, amber urine with an unpleasant odor is a common symptom of a UTI. UTIs often cause changes in urine color, odor, and clarity due to the presence of bacteria and inflammatory cells in the urine.

C. Ketone bodies in the urine: Ketones in the urine can occur in conditions such as uncontrolled diabetes or during periods of fasting. However, cloudy, amber urine with an unpleasant odor is more indicative of a UTI rather than the presence of ketones.

D. Nocturia: Nocturia refers to waking up during the night to urinate. While it may be associated with certain urinary conditions, it does not directly correlate with the appearance and odor of the urine.

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The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

Correct Answer is A

Explanation

The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

Correct Answer is B

Explanation

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