1. An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
A) Boardlike, rigid abdomen B) Loss of the urge to defecate C) Liquid stool D) Abdominal pain
2. The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
A) Omelette and hash browns B) Pancakes and syrup C) Bagel with cream cheese D) Cooked oatmeal and grapefruit half
3. One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
A) On arising and no later than 6 PM B) At evenly spaced intervals, such as 8 AM and 8 PM C) With at least one glass of water per pill D) With breakfast and at bedtime
4. The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
A) 'I - ll be sure to rise slowly and sit for a few minutes after lying down.' B) 'I - ll be sure to walk at least 2 - 3 blocks every day.' C) 'I - ll be sure to restrict my fluid intake to four or five glasses a day.' D) 'I - ll be sure not to take any more aspirin while I amon this drug.'
5. A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
A) Pork chop, baked acorn squash, brussel sprouts B) Chicken breast, rice, and green beans C) Roast beef, baked potato, and diced carrots D) Tuna casserole, noodles, and spinach
1. Right Answer: C Explanation: (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
2. Right Answer: D Explanation: (A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.
3. Right Answer: A Explanation: (A) This option provides adequate spacing of the medication and will limit the clients need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the clients usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls.
4. Right Answer: A Explanation: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 20003000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.
5. Right Answer: A Explanation: (A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option.
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