An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

• A.Boardlike, rigid abdomen
• B.Loss of the urge to defecate
• C.Liquid stool
• D.Abdominal pain

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The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?

• A."Do you take aspirin on a regular basis?"
• B."Do you drink alcohol on a regular basis?"
• C."Do you eat red meat?"
• D."Have your stools been normal?"

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A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

• A.The delirious client is capable of returning to his previous level of functioning.
• B.The delirious client is incapable of returning to his previous level of functioning.
• C.Delirium entails progressive intellectual and behavioral deterioration.
• D.Delirium is an insidious process.

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A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

• A.Not give the digoxin if the pulse is_60
• B.Not give the digoxin if the pulse is_100
• C.Take the apical pulse for a full minute
• D.Monitor for visual disturbances, a side effect of digoxin

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The nurse needs to be aware that the most common early complication of a myocardial infarction is:

• A.Diabetes mellitus
• B.Anaphylactic shock
• C.Cardiac hypertrophy
• D.Cardiac dysrhythmia

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