Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Solid with red streaks.

Formed but soft.

Brown liquid.

Tarry appearance.

Multiple hard pellets.

Answer and Explanation

Correct Answer : A,C,D,E

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

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Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

A. Acute pain. B. Neuropathic pain. C. Visceral pain. D. Nociceptive pain.

Correct Answer is B

Explanation

The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain.

Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system1.

Therefore, the nurse should document the finding as neuropathic pain.

Choice A is not correct because acute pain is a general term that does not specify the type of pain experienced by the patient.

Choice C is not correct because visceral pain refers to pain that originates from internal organs.

Choice D is not correct because nociceptive pain refers to pain caused by tissue damage or injury.

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Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?

Correct Answer is B

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?

An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain. To assess the intensity of the client's pain, which approach should the nurse use?

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?