Nokea
The clinic nurse is caring for a client who is 67 inches tall and weighs 100 kg. The client complains of occasional pyrosis, which resolves with standing or with taking antacids. Which treatment should the nurse expect the HCP to order?
- A. Place the client on a weight loss program.
- B. Instruct the client to eat three (3) balanced meals.
- C. Tell the client to take an antiemetic before each meal.
- D. Discuss the importance of decreasing alcohol intake.
Correct Answer: A
Rationale: Pyrosis (heartburn) in an overweight client (BMI ~33) suggests GERD, and weight loss reduces abdominal pressure and reflux. Balanced meals, antiemetics, and alcohol reduction are less primary.
You may also like to solve these questions
The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients?
- A. Discuss coping skills to assist with adaptation to lifestyle modifications.
- B. Teach about drug administration, dosages, and scheduled times.
- C. Teach dietary changes necessary to control symptoms.
- D. Explain the care of the ileostomy and necessary equipment.
Correct Answer: A
Rationale: Coping skills help clients adapt to the chronic, unpredictable nature of Crohn’s disease, addressing psychosocial needs in a support group. Medications, diet, and ileostomy care are secondary.
The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The HCP writes the following admission orders for the client with possible appendicitis. Which order should the nurse question?
- A. Place on NPO (nothing per mouth) status.
- B. No analgesics until diagnosis is confirmed.
- C. Apply heat to abdomen to decrease pain.
- D. Start IV lactated Ringer’s at 125 mL/hr.
Correct Answer: C
Rationale: A. Clients are kept NPO in case surgery is needed. B. Analgesic medications are usually withheld until a definitive diagnosis is established to avoid masking critical symptom changes. C. The nurse should question applying heat to the abdomen when appendicitis is suspected. Heat is contraindicated because it increases circulation, which, in turn, could cause the appendix to rupture. D. Isotonic IV fluids are initiated to replace lost body fluid and prevent dehydration.