A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

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Question 1 of 9

A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

Correct Answer: A

Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.

Question 2 of 9

A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?

Correct Answer: D

Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.

Question 3 of 9

. A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:

Correct Answer: B

Rationale: Rationale: 1. Oral antidiabetic agents target insulin resistance, common in type 2 diabetes. 2. Type 1 diabetes lacks insulin production, making oral agents ineffective. 3. Choice A is incorrect as insulin cannot be taken orally. 4. Choice C is incorrect as oral agents are not indicated for type 2 diabetes. 5. Choice D is incorrect as pregnancy does not affect the type of diabetes.

Question 4 of 9

Mr. Reyes has a possible skull fracture. The nurse should:

Correct Answer: A

Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.

Question 5 of 9

Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:

Correct Answer: C

Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure. Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.

Question 6 of 9

A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?

Correct Answer: B

Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart." Rationale: 1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity. 2. Antacids can bind to iron and reduce its absorption. 3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid. 4. Taking them together (choice A) would decrease iron absorption. 5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately. 6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.

Question 7 of 9

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?

Correct Answer: A

Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.

Question 8 of 9

Mrs. Adams is scheduled for an intravemous pyelogram (IVP). Nurse Aura wpould be most concerned if the patient makes which of the following comments or statements?

Correct Answer: A

Rationale: The correct answer is A because taking a laxative like Senokot can affect the results of an IVP by altering bowel motility and potentially causing inaccurate imaging. Choice B is related to bladder sensation, which is not directly relevant to an IVP. Choice C indicates a possible allergic reaction to mussels, which is unrelated to the procedure. Choice D mentions headaches, which are also not directly linked to an IVP. In summary, only choice A directly impacts the accuracy of the IVP results, making it the most concerning statement for Nurse Aura.

Question 9 of 9

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?

Correct Answer: C

Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.

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