Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
A. Ignoring the urge to defecate
Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
B. Increased fiber in the diet
Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
C. Excessive laxative use
Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
D. Increased activity
Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
Choice B reason: Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
Choice C reason: Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
Choice D reason: Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
Similar Questions
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
A. Plan to administer insulin to the client.
Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
B. Have the client breathe into a paper bag.
Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
C. Plan to administer sodium bicarbonate to the client.
Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
D. Have the client place their head between their knees.
Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.
Full Explanation
Choice A reason: Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
Choice B reason: Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
Choice C reason: Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
Choice D reason: Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.
A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?
A. Wheezing
Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not hyperkalemia. Hyperkalemia affects the muscular function and cardiac conduction rather than causing respiratory symptoms.
B. Decreased deep tendon reflexes
Decreased deep tendon reflexes occur due to the effect of hyperkalemia on the neuromuscular junction and muscle excitability. In hyperkalemia, the resting membrane potential of muscle cells is less negative, which makes them less responsive to stimuli.
C. Hypoactive bowel sounds
Hypoactive bowel sounds are generally associated with gastrointestinal issues and are not a direct manifestation of hyperkalemia. While severe hyperkalemia can affect smooth muscle function, it is not typically characterized by changes in bowel sounds.
D. Cerebral edema
Cerebral edema is not a manifestation of hyperkalemia. It is usually caused by traumatic brain injury, infections, or other neurological conditions. Hyperkalemia primarily affects muscular function and cardiac conduction.
Full Explanation
The correct answer is B. Decreased deep tendon reflexes. Hyperkalemia can lead to muscle weakness and decreased reflexes, which is a common manifestation in patients with chronic kidney disease.
Choice A reason:
Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not hyperkalemia. Hyperkalemia affects the muscular function and cardiac conduction rather than causing respiratory symptoms.
Choice B reason:
Decreased deep tendon reflexes occur due to the effect of hyperkalemia on the neuromuscular junction and muscle excitability. In hyperkalemia, the resting membrane potential of muscle cells is less negative, which makes them less responsive to stimuli.
Choice C reason:
Hypoactive bowel sounds are generally associated with gastrointestinal issues and are not a direct manifestation of hyperkalemia. While severe hyperkalemia can affect smooth muscle function, it is not typically characterized by changes in bowel sounds.
Choice D reason:
Cerebral edema is not a manifestation of hyperkalemia. It is usually caused by traumatic brain injury, infections, or other neurological conditions. Hyperkalemia primarily affects muscular function and cardiac conduction.
Normal serum potassium levels range from about 3.5 to 5.0 mmol/L. Hyperkalemia is defined as serum potassium levels above 5.0 mmol/L.
A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?
A. Wheezing
Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.
B. Decreased deep tendon reflexes
Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.
C. Hypoactive bowel sounds
Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.
D. Cerebral edema
Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.
Full Explanation
The correct answer is b. Decreased deep tendon reflexes.
Choice A: Wheezing
Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.
Choice B: Decreased deep tendon reflexes
Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.
Choice C: Hypoactive bowel sounds
Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.
Choice D: Cerebral edema
Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.