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

Determine the client's usual bowel patern

Encourage the client to ambulate more frequently

Recommend increasing high-fiber foods daily

Answer and Explanation

The Correct Answer is B

A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may aﬀect the client's bowel function.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or eﬀective.

Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.

Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.

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Correct Answer is C

Explanation

Choice A rationale:

A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.

Choice B rationale:

The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.

Choice C rationale:

Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.

Choice D rationale:

Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.

A. Ask the mother if any visitors were expected to arrive. B. Match ID bands of all infants and mothers on the unit. C. Determine if the newborn is in the nursery. D. Activate the lockdown procedure.

Correct Answer is D

Explanation

The correct answer is D. Activate the lockdown procedure.

Choice A rationale:

Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.

Choice B rationale:

Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.

Choice C rationale:

Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.

Choice D rationale:

Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Correct Answer is D

Explanation

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