Which assessment technique will the nurse use first when ...

[gbarreiro]

Which assessment technique will the nurse use first when examining a client with a fecal elimination problem?
 
  1. Auscultation
  2. Inspection
  3. Palpation
  4. Percussion

Question 2

The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client?
 
  1. Client will defecate regularly.
  2. Client will increase the amount of sugar in the diet.
  3. Client will limit fluid intake.
  4. Client will regain normal stool consistency.

[frogdreck123456]

Answer to Question 1

Correct Answer: 2
Rationale 1: After inspection, the nurse should then auscultate for bowel sounds.
Rationale 2: The nurse will first inspect the client's abdominal region.
Rationale 3: This technique would be used last in the assessment of a client with a fecal elimination problem.
Rationale 4: This technique would be used after inspection and auscultation.

Answer to Question 2

Correct Answer: 4
Rationale 1: Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal. The problem needs to be corrected first.
Rationale 2: Increasing the amount of sugar in the diet will just add to the diarrhea.
Rationale 3: Because the client is experiencing diarrhea, which can dehydrate the client and promote electrolyte loss, limiting fluid would not be appropriate.
Rationale 4: Because this client is experiencing diarrhea, the goal would be to regain normal stool consistency, which would be less water in the stool and a more formed consistency.