Which outcome is expected for a client who has a diagnosis of constipation? The client:.
Takes a laxative daily.
Has a return to their normal bowel habits.
Requests a bedpan every four hours.
Has a bowel movement within 72 hours.
The Correct Answer is B
This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.
Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.
Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.
Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A client with dehydration will have increased heart rate and decreased blood pressure due to the loss of fluid volume and the compensatory mechanisms to maintain cardiac output.
Choice C is wrong because dehydration does not cause increased temperature, but rather decreased temperature due to reduced blood flow to the skin.
Choice D is wrong because dehydration causes hyperactive muscle responses, such as muscle cramps, twitching, and tetany.
Choice E is wrong because dehydration can cause altered mental status, such as confusion, lethargy, or coma. Normal ranges for heart rate are 60-100 beats per minute, blood pressure is 120/80 mm Hg, and temperature is 36.5-37.5°C (97.7-99.5°F).
Correct Answer is B
Explanation
Notify the health care provider. The nurse should take this action first because the provider can prescribe appropriate interventions to prevent or minimize harm to the client.
The nurse should also inform the unit supervisor, document the error in the client’s medical record, and record the error on the appropriate quality improvement report, but these are not the priority actions.
Choice A is wrong because informing the unit supervisor is not the most urgent action. The supervisor can provide support and guidance to the nurse, but cannot prescribe interventions for the client.
Choice C is wrong because documenting the error in the client’s medical record is not the most urgent action.
The nurse should document the error after notifying the provider and assessing the client. Documentation should include the medication name, dose, route, time, client’s response, and actions taken.
Choice D is wrong because recording the error on the appropriate quality improvement report is not the most urgent action.
The nurse should record the error after notifying the provider and assessing the client. The report should include a factual description of what happened and what was done.
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