which of the following statements indicates adequate dietary understanding in a client with constipation
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which of the following statements indicates adequate dietary understanding in a client with constipation?

Correct answer: C

Rationale: The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.

2. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?

Correct answer: D

Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.

3. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

Correct answer: C

Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.

4. The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?

Correct answer: C

Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed. Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions. Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.

5. The client is unsure about making medical decisions as their disease progresses and wants to appoint someone to make these decisions. Which of the following options would be most appropriate?

Correct answer: C

Rationale: The correct answer is 'a healthcare proxy.' A healthcare proxy involves the client appointing an individual to make medical decisions on their behalf if they become unable to do so. This option allows the client to choose someone they trust to act in their best interests. Choice A, 'a living will,' is a legal document that outlines a person's wishes regarding medical treatment in case they are unable to communicate their decisions. While it is important, it does not involve appointing someone to make decisions. Choice B, 'informed consent,' is a process where a healthcare provider explains a treatment or procedure, including its risks and benefits, to a patient who can then decide whether to proceed. This is not about appointing someone to make decisions on the patient's behalf. Choice D, 'non-informed consent,' is not a valid concept in healthcare. Informed consent is crucial for respecting a patient's autonomy and decision-making capacity.

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