Bowel
A nurse is assessing a patient with a history of constipation. The patient reports having bowel movements only once or twice a week and experiencing difficulty passing stools. Which of the following interventions would be most appropriate for the nurse to recommend?
A) Decrease fluid intake to reduce stool volume.
B) Recommend a diet low in fiber and high in processed foods.
C) Suggest incorporating more high-fiber foods like legumes, fruits, and whole grains into the diet.
D) Advise the patient to avoid exercise to prevent abdominal discomfort.
Answer: C
Rationale: A high-fiber diet adds bulk to the stool and promotes peristalsis, which facilitates the passage of stool through the intestines, addressing the patient's constipation. Decreasing fluid intake can worsen constipation. A low-fiber diet contributes to constipation. Exercise promotes bowel motility and is beneficial.
A nurse is caring for a patient who is scheduled for a potentially life-saving experimental treatment. The patient expresses concerns about potential side effects. Which ethical principle should the nurse prioritize in this situation?
A) Justice
B) Beneficence
C) Nonmaleficence
D) Fidelity
Answer: C) Nonmaleficence
Rationale: The principle of nonmaleficence is the obligation to avoid subjecting another to harm or the risk of harm. In this scenario, the patient is weighing the risks and benefits of a treatment, and the nurse should prioritize minimizing potential harm. Beneficence (doing good) is also a factor, but the immediate concern is the patient's worry about harm.
A patient with a history of heart disease has been prescribed a low-cholesterol diet. Which of the following food choices would be most appropriate for the nurse to include in the patient's meal plan?
A. Beef liver and whole milk
B. Salmon and sweet potatoes
C. Pork and cheese
D. Lamb and coconut oil
Answer: B
Rationale: A low-cholesterol diet restricts foods high in saturated fats. Salmon and sweet potatoes are good choices as they are lower in saturated fats and can support a low-cholesterol diet. Beef liver, whole milk, pork, cheese, lamb, and coconut oil are high in saturated fats, which should be limited in this diet.
An older adult patient reports experiencing nocturia. Which of the following age-related changes in the urinary system contributes to this condition?
A) Increased bladder capacity
B) Decreased blood flow to the kidneys
C) Weakened urinary sphincters (more common in men)
D) Increased number of nephrons
Answer: B
Rationale: Nocturia, or excessive urination at night, is associated with decreased blood flow to the kidneys in older adults. This change impairs the kidney's ability to concentrate urine, leading to increased nighttime urination.
A nurse is caring for a client experiencing moderate anxiety. Which of the following interventions would be most appropriate?
A. Leaving the client alone to allow them to regain composure.
B. Offering simple, brief directions and encouraging problem-solving.
C. Administering anti-anxiety medication and limiting environmental stimuli.
D. Speaking loudly and rapidly to redirect the client's attention.
Answer: B
Rationale: Moderate anxiety narrows the perceptual field, but the individual can still process information. Simple, brief directions and encouraging problem-solving can help the client focus and cope. Leaving the client alone (A) is inappropriate as they need support. While medication (C) might be used, it's not the most appropriate initial intervention. Speaking loudly and rapidly (D) will likely escalate anxiety.
A nurse is performing an abdominal assessment on a patient complaining of abdominal pain. In which order should the nurse perform the following techniques?
A) Auscultation, Palpation, Percussion, Inspection
B) Inspection, Palpation, Auscultation, Percussion
C) Inspection, Auscultation, Percussion, Palpation
D) Palpation, Percussion, Inspection, Auscultation
Answer: C
Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, and then Palpation. Palpation can alter bowel sounds and abdominal findings, so it is performed last
A nurse discovers that a colleague has been documenting vital signs that were not actually taken. The nurse is unsure whether to report this behavior. Which ethical principle is most challenged in this situation?
A) Justice
B) Beneficence
C) Nonmaleficence
D) Fidelity
Answer: D) Fidelity
Rationale: Fidelity is the obligation to act in ways that are loyal. In this context, it includes loyalty to the profession, to the employing agency, and to the patient. Falsifying records is a breach of this principle.
A patient with gallbladder disease is prescribed a fat-restricted diet. Which dietary instruction is most important for the nurse to provide?
A. "Increase your intake of nuts and seeds for added protein."
B. "Limit your consumption of fried foods and rich desserts."
C. "Focus on incorporating more whole grains into your meals."
D. "Ensure you are eating enough raw fruits and vegetables."
Answer: B
Rationale: A fat-restricted diet is used for patients with gallbladder disease, and it's important to avoid fatty foods. Therefore, limiting fried foods and rich desserts is a key instruction. Nuts, while nutritious, are high in fat. Whole grains, raw fruits, and vegetables are not the primary concern in a fat-restricted diet.
A nurse is assessing a patient's urine and observes that it is cloudy. Which of the following characteristics is considered a normal finding in a urinalysis?
A) Turbidity
B) Color - Amber
C) Clarity - Clear
D) pH - 9.0
Answer: C
Rationale: Normal urine should be clear, not turbid or cloudy. The normal color of urine is yellow, and the pH range is 4.6-8, with an average of 6
A client involved in a motor vehicle accident resulting in the loss of a limb is exhibiting denial and anger. The nurse recognizes that the client is demonstrating:
A. Effective coping mechanisms.
B. Maladaptive coping mechanisms.
C. Problem-focused coping.
D. Emotion-focused coping.
Answer: B
Rationale: Denial and anger can be indicators of maladaptive coping, especially when they interfere with the client's ability to adapt to a new reality and engage in recovery. While emotion-focused coping (D) is a type of coping, in this case, the behaviors are maladaptive.
A patient reports to the clinic that they have been having frequent episodes of bowel incontinence. The nurse knows that this condition can lead to which of the following complications?
A) Increased appetite
B) Urinary retention
C) Skin breakdown
D) Hypertension
Answer: C
Rationale: Bowel incontinence can lead to skin breakdown due to moisture-associated skin damage. It does not directly cause increased appetite, urinary retention, or hypertension.
In a busy emergency department, a nurse must prioritize care for multiple patients. Which ethical theory would best guide the nurse in making these decisions?
A) Ethics of Duty
B) Ethics of Consequence
C) Ethics of Character
D) Ethics of Relationship
Answer: B) Ethics of Consequence
Rationale: Ethics of consequence, also known as utilitarianism, focuses on the greatest good for the greatest number. In an emergency setting, the nurse often has to make decisions that maximize benefit for the most patients, which aligns with this theory.
A patient with a history of hypertension is placed on a sodium-restricted diet. The nurse should educate the patient to carefully read food labels to avoid which of the following?
A. Poultry and dairy products
B. Fresh fruits and vegetables
C. Processed foods and smoked meats
D. Whole grains and legumes
Answer: C
Rationale: Sodium-restricted diets are used for patients with cardiovascular diseases like hypertension. Processed foods and smoked meats are typically high in sodium and should be avoided. Poultry, dairy, fresh fruits, vegetables, whole grains, and legumes are not typically high in sodium unless salt is added during processing or preparation.
A patient is diagnosed with a urinary tract infection (UTI). The nurse is reviewing prevention strategies with the patient. Which of the following should the nurse include in the teaching?
A) Wear tight clothing
B) Take baths instead of showers
C) Drink at least four 8-ounce glasses of water per day
D) Wear underwear with a cotton-lined crotch
Answer: D
Rationale: To prevent UTIs, it is recommended to wear underwear with a cotton-lined crotch, avoid tight clothing, drink at least eight 8-ounce glasses of water per day, and take showers instead of baths.
When assessing a client's coping mechanisms, which factors indicate a higher risk for ineffective coping?
A. The client has a history of successfully managing stressful situations.
B. The client expresses a perceived lack of support.
C. The client demonstrates an ability to accurately assess the stressor.
D. The client has adequate cognitive function.
Answer: B
Rationale: A perceived lack of support is a significant risk factor for maladaptive coping. A history of successful coping (A), accurate stressor assessment (C), and adequate cognition (D) are protective factors
A nurse is teaching a patient about risk factors for constipation. Which of the following factors should the nurse include?
A) Regular exercise
B) Neurologic disorders
C) High fiber diet
D) Excessive laxative use
Answer: B, D
Rationale: Neurologic disorders and excessive laxative use are risk factors for constipation. Regular exercise and a high-fiber diet help prevent constipation.
A nurse is caring for a patient who is considering participating in a research study. Which actions by the nurse demonstrate respect for persons?
A) Ensuring the patient is aware of their right to refuse participation.
B) Providing the patient with all the details of the study, including potential risks and benefits.
C) Discussing the study with other healthcare professionals involved in the patient's care.
D) Maintaining the patient's privacy during discussions about the study.
Answer: A, B, and D
Rationale: Respect for persons includes autonomy and veracity.
Question 4 (Hard Difficulty) (Select All That Apply)
The nurse is caring for a patient with GERD. Which of the following dietary modifications should the nurse include in the patient's education? Select all that apply.
A. Avoidance of spicy foods
B. Consumption of 3 large meals per day
C. Limiting fluid intake with meals
D. Avoidance of chocolate
Answer: A and D
Rationale: For GERD management, it is recommended to avoid spicy foods and chocolate. Patients should consume 6 small meals instead of 3 large meals, and they are not instructed to limit fluids with meals
Which of the following are risk factors for urinary elimination problems?
A) Pregnancy
B) Older age
C) Spinal cord injury
D) High fluid intake
Answer: A, B, C
Rationale: Pregnancy and older age are identified as populations at greater risk for urinary elimination problems. Spinal cord injuries can cause temporary or permanent urinary incontinence. High fluid intake is generally not a risk factor; inadequate fluid intake is more likely to cause issues
Which physiological responses are commonly associated with the body's reaction to stress? Select all that apply.
A. Increased heart rate
B. Slowed digestion
C. Increased fluid loss
D. Increased blood glucose
Answer: A, B, D
Rationale: The sympathetic nervous system's response to stress includes increased heart rate, slowed digestion, and increased blood glucose. Reduced fluid loss, not increased fluid loss, is a physiological response to stress.
The nurse is assessing a patient's abdomen and notes distention. Which of the following could be contributing factors to the distention?
A) Ascites
B) Hernia
C) Normal bowel sounds
D) Protuberant abdomen
Answer: A, B, D
Rationale: Abdominal distention can be caused by ascites, hernia, and a protuberant abdomen. Normal bowel sounds are not a cause of distention
Which of the following situations represent potential sources of moral distress for a nurse?
A) Being asked to administer a medication with which the nurse disagrees with.
B) Feeling unable to provide adequate pain relief to a patient due to understaffing.
C) Witnessing a colleague make a medication error that is quickly corrected.
D) Being pressured to provide care that the nurse believes is not in the patient's best interest.
Answer: A, B, and D
Rationale: Moral distress occurs when a person is unable to take what he or she believes is the morally appropriate action or when a person acts in a manner contrary to his or her personal and professional values.
A nurse is providing nutritional counseling to a client. Which of the following statements are accurate regarding macronutrients? Select all that apply.
A. Carbohydrates are the body's primary energy source and are converted to glucose.
B. Lipids, or fats, are a secondary source of energy and aid in body protection.
C. Proteins are the most abundant fats.
D. The body stores carbohydrates.
Answer: A and B
Rationale: Carbohydrates are indeed the body's primary energy source and are converted to glucose. Lipids (fats) serve as a secondary energy source and provide body protection. Triglycerides are the most abundant form of fats, not proteins. The body does not store carbohydrates; they must be consumed throughout the day.
Which of the following are potential consequences of urinary retention?
A) Pyelonephritis
B) Renal atrophy
C) Increased urine output
D) Bladder distention
Answer: A, B, D
Rationale: Urinary retention can lead to increased urine volume and bladder distention. The backflow of urine can cause dilation of the ureters and renal pelvis, potentially leading to pyelonephritis and renal atrophy. It does not lead to increased urine output; rather, it is the opposite.
A nurse is planning care for a client experiencing anxiety. Which interventions should be included? Select all that apply.
A. Pharmacotherapy
B. Cognitive behavioral therapy (CBT)
C. Prolonged exposure therapy
D. Regular exercise
Answer: A, B, C, D
Rationale: Pharmacotherapy, CBT, prolonged exposure therapy, and regular exercise are all recognized interventions for managing anxiety.