An older adult is admitted through the emergency department with complaints of nausea, abdominal tenderness, and continual stooling
On assessment, the nurse notes abdominal distention, smearing of stool on undergarments, and hypoactive bowel sounds LUQ and LLQ. The patient is unable to determine when the last bowel movement was. What is the nurse's priority assessment?
a. Signs and symptoms of an infection
b. An impaction
c. A pattern of laxative abuse
d. History of GI disease
ANS: B
A nursing priority is to determine basic needs such as last bowel movement, constipation, and pain control. The symptoms presented do not indicate an infection as a priority. Frequent stooling indicated by the history and smearing on the undergarments are signs of an impaction, or an area of hardened stool. Laxative abuse or a history of GI disease may be contributing factors that the health care provider will review. Although the patient may have an infection or history of GI disease, checking for an impaction is a higher priority because it is done more quickly and is more likely to yield results. These symptoms are not characteristic of laxative abuse.
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