HESI Registered Nurse EXIT Practice Exam

Which nursing assessment finding would indicate the probable presence of fecal impaction in a paralyzed client?

1. Presence of blood in stools

2. Oozing liquid stool

3. Continuous rumbling flatulence

4. Absence of bowel movements

The correct answer is: Oozing liquid stool

The presence of oozing liquid stool is an important assessment finding that can indicate fecal impaction, especially in a paralyzed client. Fecal impaction occurs when a large mass of hardened stool gets stuck in the intestines, preventing normal bowel movements. The impaction can lead to a situation where the liquid stool, produced by the bowel, can only escape around the obstruction. This results in liquid stool leaking out, giving the appearance of diarrhea, while the underlying issue of impaction remains unaddressed. In the case of a paralyzed client, their inability to move and reduced bowel motility increase the risk of not having regular, effective bowel movements, making it crucial to carefully assess these signs. Recognizing that oozing liquid stool does not solve the problem but rather signals a complication, allows the nursing staff to intervene promptly, which can include manual disimpaction or administering other treatments to alleviate the condition. The other options do not specifically indicate fecal impaction. Presence of blood in the stools might suggest other gastrointestinal issues. Continuous rumbling flatulence could indicate normal bowel activity or just gas, and absence of bowel movements can point to several issues, but by itself does not confirm impaction without additional context. Understanding these distinctions