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A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?
- A. The child is free of diarrhea.
- B. The child is free of bloody stools.
- C. The child tolerates dietary wheat and rye.
- D. A balanced fluid and electrolyte status is noted on the laboratory results.
Correct Answer: A
Rationale: Watery diarrhea is a frequent clinical manifestation of celiac disease. The absence of diarrhea indicates effective treatment. Bloody stools are not associated with this disease. The grains of wheat and rye contain gluten and are not allowed. A balance of fluids and electrolytes does not necessarily demonstrate the improved status of celiac disease.
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The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?
- A. Urinary output is increased.
- B. Presence of trace urinary protein
- C. Client complaints of blurred vision
- D. Blood pressure reading at prenatal baseline
Correct Answer: C
Rationale: Client complaints of headache or blurred vision indicate a worsening of the condition and warrant immediate further evaluation. The remaining options are all signs that the gestational hypertension is being resolved.
The nurse is providing instructions to the mother of a child with a diagnosis of strabismus of the left eye. Which statement by the mother indicates that the mother understands the procedure for patching?
- A. I will place the patch on both eyes.
- B. I will place the patch on the left eye.
- C. I will place the patch on the right eye.
- D. I will alternate the patch from the right eye to the left eye every hour.
Correct Answer: C
Rationale: Patching may be used for the treatment of strabismus to strengthen the weak eye. With this treatment, the good eye is patched; this encourages the child to use the weaker eye. The treatment is most successful when it is performed during the preschool years. The schedule for patching is individualized and prescribed by the ophthalmologist.
A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?
- A. Edema present at 3+
- B. Weight loss of 5 pounds within 2 days
- C. Pulse rate increased from 58 to 74 beats/min
- D. Blood pressure decreased from 142 / 94mmHg to 128 / 82mmHg
Correct Answer: D
Rationale: Betaxolol is a beta-adrenergic blocking agent used to lower blood pressure, relieve angina, or eliminate dysrhythmias. Side/adverse effects include bradycardia and symptoms of heart failure, such as weight gain and increased edema.
A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom?
- A. Diarrhea
- B. Bleeding
- C. Infection
- D. Epigastric pain
Correct Answer: D
Rationale: The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol is administered to prevent this occurrence. Diarrhea can be a side effect of the medication, but its relief is not an intended effect. Bleeding and infection are unrelated to the question.
The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
- A. Daily weight
- B. Calorie count
- C. Skinfold measurement
- D. Serum prealbumin level
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.