A nurse is assessing a client who has had diarrhea for several days.
Which of the following findings should the nurse expect?
Hypothermia.
Rigid abdomen.
Decreased bowel sounds.
Dehydration.
The Correct Answer is D
Choice A rationale
Hypothermia is not commonly associated with diarrhea. Diarrhea typically leads to fluid loss and dehydration rather than changes in body temperature.
Choice B rationale
A rigid abdomen is not a typical finding for diarrhea. It may indicate other gastrointestinal issues, such as peritonitis, rather than dehydration caused by diarrhea.
Choice C rationale
Decreased bowel sounds are not typically expected with diarrhea, which often presents with increased bowel sounds due to increased motility.
Choice D rationale
Dehydration is a common finding in clients with diarrhea due to the excessive loss of fluids and electrolytes from frequent, loose stools. It can lead to symptoms such as dry mouth, reduced urine output, and dizziness.
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Correct Answer is C
Explanation
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.
Correct Answer is D
Explanation
Choice D rationale
Intravenous (IV) administration has the fastest rate of absorption because the medication is delivered directly into the bloodstream, bypassing the absorption barriers of the digestive
system or muscle tissue. This ensures rapid onset of action.
Choice A rationale
Enteral administration involves the gastrointestinal tract, including oral and feeding tube methods. Absorption is slower as the medication passes through the digestive system before
entering the bloodstream.
Choice B rationale
Intramuscular (IM) administration involves injecting the medication into muscle tissue, where it is absorbed into the bloodstream. Absorption is quicker than enteral routes but slower
compared to IV administration.
Choice C rationale
Topical administration involves applying medication to the skin or mucous membranes. Absorption is generally slower and is intended for local or systemic effects, depending on the medication.