When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago.”. Which action should the PN implement first?
Administer a prescribed PRN stool softener.
Encourage client to ambulate more frequently.
Recommend increasing high fiber foods daily.
Determine the client's usual bowel pattern.
The Correct Answer is D
Determine the client's usual bowel pattern.
Choice A rationale:
Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.
Choice B rationale:
Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.
Choice C rationale:
Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.
Choice D rationale:
Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
No explanation
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A: Excruciating pain
- Rationale: While partial thickness burns can be painful, especially in the first few days, excruciating pain is less likely for a stable patient 3 days post-burn. Pain management is a crucial aspect of burn care, but excruciating pain might indicate deeper burns or complications like infection.
Choice B: Elevated blood pressure
- Rationale: Elevated blood pressure is not a typical complication of a partial thickness burn. In fact, burn patients are more at risk for hypotension (low blood pressure) due to fluid loss.
Choice C: Compartment syndrome
- Rationale: Compartment syndrome is a serious complication that typically occurs with deep burns or traumatic injuries. It's caused by increased pressure within a muscle compartment, restricting blood flow and potentially leading to tissue death. While a possibility, it's less likely for a partial thickness burn 3 days after the injury.
Choice D: Curling's Ulcer
- Rationale: Curling's ulcer is a peptic ulcer (stomach ulcer) that can develop as a complication of major burns. This is because burns trigger a massive inflammatory response, releasing stress hormones that increase stomach acid production, making the stomach lining more susceptible to ulcers. Given the extensive burn area (30% TBSA) and the timeframe (3 days post-burn), Curling's ulcer becomes a significant concern.
Therefore, the correct answer is: Choice D: Curling's Ulcer
Explanation:
- A 30% TBSA partial thickness burn is a significant injury that triggers a systemic inflammatory response.
- Three days post-burn falls within the timeframe when Curling's ulcer can develop due to the increased stress hormones and gastric acid production.
- While pain management and monitoring for compartment syndrome are important, Curling's ulcer poses a more significant threat in this scenario.
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