Which client would be at risk for mechanical obstruction of the intestine?
A client with muscular dystrophy.
A client with Parkinson's disease.
A client with colon cancer.
A client with diabetes mellitus.
The Correct Answer is C
Choice A rationale
Muscular dystrophy is a genetic disorder characterized by progressive muscle weakness and degeneration. While it can affect the smooth muscles of the gastrointestinal tract, it typically leads to functional issues like paralytic ileus or decreased motility rather than a mechanical obstruction. Mechanical obstructions are physical barriers that block the flow of contents through the lumen. In muscular dystrophy, the problem is usually a lack of effective peristalsis (functional) rather than a physical mass or structural blockage within the intestinal pipe.
Choice B rationale
Parkinson's disease is a neurodegenerative disorder that primarily affects movement and coordination. It often leads to significant constipation and slow colonic transit due to autonomic nervous system dysfunction and the effects of medications. This results in a functional obstruction where the muscles do not move waste efficiently. It is not considered a mechanical obstruction unless the chronic constipation leads to a severe fecal impaction that physically blocks the lumen, but the primary pathology itself is neurological and functional.
Choice C rationale
Colon cancer is a leading cause of mechanical intestinal obstruction. As a tumor grows within the lumen of the large intestine, it physically narrows the passage, eventually preventing the movement of stool and gas. This is a structural or anatomical barrier that requires medical or surgical intervention to clear. Other examples of mechanical obstructions include adhesions, hernias, and volvulus. Cancer cells infiltrate the bowel wall and create a fixed mass, which is a classic example of a mechanical blockage.
Choice D rationale
Diabetes mellitus can lead to gastrointestinal complications such as gastroparesis or diabetic enteropathy due to autonomic neuropathy. These conditions result from nerve damage that impairs the normal rhythmic contractions of the intestines, leading to slow emptying and functional stasis. While this can cause symptoms similar to an obstruction, it is not a mechanical or structural blockage. The underlying issue is the failure of the nerves to signal the muscles to move, rather than a physical object blocking the path.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual. It is supported by risk factors rather than current signs or symptoms. Since this client is currently experiencing a pain level of 7 out of 10, the problem is not a potential future occurrence but a current reality. Therefore, a risk diagnosis is insufficient because it does not address the physiological and psychological distress the client is actively feeling.
Choice B rationale
An actual nursing diagnosis represents a clinical judgment about a patient's response to a health condition that is currently present. It is validated by the presence of defining characteristics, such as the client's self-report of pain at a level of 7 on a 0 to 10 scale. Because the pain is a real-time problem requiring immediate nursing intervention and management, this category is the most appropriate to guide the care plan, aiming to reduce the intensity of the subjective discomfort.
Choice C rationale
A possible nursing diagnosis is used when the nurse suspects a problem may be present but requires more data to confirm it. In this scenario, there is no ambiguity; the client has clearly stated their pain level is high. Using a possible diagnosis would inappropriately delay necessary pharmacological or non-pharmacological interventions. Since the evidence of the pain is already documented through the client's verbalization, the diagnosis is confirmed and should be treated as a definitive clinical priority.
Choice D rationale
A wellness diagnosis, also known as a health promotion diagnosis, focuses on a client's transition from a specific level of wellness to a higher level of wellness. It is used when a client expresses a desire to enhance their health. A postoperative client experiencing significant pain is in a state of acute physiological stress, not a state of seeking optimal wellness. The priority in this case is the management of an acute symptom rather than long-term health optimization.
Correct Answer is D
Explanation
Choice A rationale
Excoriated skin is a significant concern due to the enzymes and acidity found in liquid stool, which can lead to rapid skin breakdown in the perianal area. While painful and a risk for secondary infection, it is usually localized and not immediately life-threatening. Proper barrier creams and hygiene can manage this issue. While important for nursing care, it does not carry the same systemic urgency as the loss of vital body fluids.
Choice B rationale
Malnutrition can occur if diarrhea is chronic, as rapid transit time through the intestines prevents the adequate absorption of nutrients, vitamins, and minerals. However, malnutrition is typically a slow-developing complication rather than an acute physiological emergency. In the context of a client currently experiencing diarrhea, the nurse must prioritize immediate stability over long-term nutritional status. Acute fluid loss poses a much more immediate threat to the client's physiological homeostasis.
Choice C rationale
Urinary incontinence is generally not a direct physiological result of diarrhea, although the urgency of diarrhea might cause accidental soiling. While it presents a challenge for hygiene and comfort, it is not a physiological response that threatens the client's vital signs or organ function. The nurse should address incontinence through frequent rounding and skin care, but it remains a lower priority compared to the systemic effects of significant fluid and electrolyte depletion.
Choice D rationale
Dehydration is the most critical concern because diarrhea involves the rapid loss of water and essential electrolytes like potassium and sodium. Severe dehydration leads to decreased circulating blood volume, which can cause hypotension, tachycardia, and potentially hypovolemic shock. Normal fluid balance is essential for cellular function and organ perfusion. Because diarrhea bypasses the large intestine's ability to reabsorb water, the risk of rapid systemic collapse makes dehydration the primary nursing priority.
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