Nokea
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.
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The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. Which question should the nurse ask to identify behaviors suggesting bulimia?
- A. When was the last time you exercised?
- B. What over-the-counter medications do you take?
- C. How long have you had a positive self-image?
- D. Do you eat a lot of high-fiber foods for bowel movements?
Correct Answer: B
Rationale: Asking about OTC medications identifies purging behaviors (e.g., laxatives, diuretics) common in bulimia. Exercise, self-image, and fiber intake are less specific.
The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?
- A. Teach the client to limit use of alcohol and drugs containing acetaminophen.
- B. Provide a high-protein, high-carbohydrate diet with three large meals per day.
- C. Wear gloves, mask, and gown when providing the client’s personal cares.
- D. Provide rest periods, alternating this with moderate activity during the day.
Correct Answer: D
Rationale: A. Clients with viral hepatitis should avoid all alcohol and all medications containing acetaminophen, not just limit their use. B. Clients should eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. C. It is not necessary to wear a mask when caring for an individual with hepatitis A. A gown and gloves should be worn when in contact with blood and body fluids. D. Rest is an essential intervention to decrease the liver’s metabolic demands and increase its blood supply. Rest should be alternated with periods of activity to prevent complications and to restore health.
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 nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?
- A. Provide a diet that is low in residue
- B. Check the colostomy bag for stool amount
- C. Assess the perineal dressing for drainage
- D. Encourage the client to see the colostomy site
Correct Answer: C
Rationale: The perineal incision must be examined frequently to assess for drainage and the need for dressing changes.
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.