which of the following reasons is the most likely cause of constipation in a client

NCLEX-RN

NCLEX RN Exam Prep

1. Which of the following is the most likely cause of constipation in a client?

A. Postponing bowel movement when the urge to defecate occurs
B. Intestinal infection
C. Antibiotic use
D. Food allergies

Correct answer: A

Rationale: The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.

2. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?

A. "The numbers are within the normal range and are nothing to worry about."?
B. "The bottom number is the diastolic pressure and reflects the pressure in the arteries when the heart relaxes."?
C. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."?
D. "The concept of blood pressure can be complex. The primary thing to be concerned about is the top number, or the systolic blood pressure."?

Correct answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

3. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?

A. Pull out that page of the chart and rewrite it with the correct information.
B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
D. All of the above are incorrect.

Correct answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

4. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

A. The client most likely has a mental illness that should be treated before addressing sleep issues
B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
C. The client may become tired once they start talking
D. None of the above

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

5. After change-of-shift report, which patient should the nurse assess first?

A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.