Nokea
The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client has a sore throat.
- B. The client appears drowsy following the procedure.
- C. The client has epigastric pain.
- D. The client experiences hematemesis.
Correct Answer: C,D
Rationale: Epigastric pain and hematemesis after a gastroscopy may indicate complications such as perforation or bleeding. A sore throat and drowsiness are expected post-procedure effects due to throat irritation and sedation.
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A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
- A. A limit of least 3,000 mL of fluid each day.
- B. Minimize daily activities.
- C. Keep urine alkaline to prevent urinary tract infections.
- D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
- E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
The nurse is assessing a client with age-related cataracts. Which of the following assessment findings would support this diagnosis of age-related cataracts?
- A. peripheral vision loss
- B. central vision loss
- C. difficulty seeing at night, especially while driving
- D. blurred vision with headache
Correct Answer: C
Rationale: Age-related cataracts often cause difficulty seeing at night, particularly while driving, due to lens opacity scattering light. Peripheral vision loss is more associated with glaucoma, central vision loss with macular degeneration, and blurred vision with headache is typical of angle-closure glaucoma.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
Which of the following should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply.
- A. Diminished hair on scalp and pubic areas.
- B. Dusky rubor of left lower extremity.
- C. Solar lentigo.
- D. Wrinkless.
- E. Yellow pigmentation.
Correct Answer: A,C,D
Rationale: Normal aging includes diminished hair, solar lentigo (age spots), and wrinkles. Dusky rubor suggests vascular issues, and yellow pigmentation may indicate jaundice, not normal aging.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
- A. Speaking loudly.
- B. Using a picture board.
- C. Writing directions so client can read them.
- D. Speaking in short sentences.
Correct Answer: B
Rationale: A picture board is most helpful for expressive aphasia, allowing the client to point to images to communicate needs. Speaking loudly, writing directions, or short sentences are less effective for clients unable to verbalize.