Nokea
The nurse is conducting a focused assess of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:
- A. Paralytic ileus.
- B. Gastric distention.
- C. Hiatal hernia.
- D. Curling's ulcer.
Correct Answer: D
Rationale: Burn injuries increase stress and metabolic demand, predisposing clients to Curling's ulcer, a stress-related gastric ulcer, due to reduced mucosal protection.
You may also like to solve these questions
A client is admitted from the emergency department after falling down a flight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply.
- A. Are you experiencing numbness in your extremities?'
- B. How much vitamin B12 are you getting?'
- C. Are you feeling depressed?'
- D. Do you feel safe at home?'
- E. Are you getting sufficient iron in your diet?'
Correct Answer: A,B,D
Rationale: Gastric stapling can impair vitamin B12 absorption, and neomycin may further reduce B12 levels by altering gut flora. The client's clumsiness and falls suggest possible B12 deficiency neuropathy, warranting questions about numbness and B12 intake. Asking about safety at home is crucial to assess for environmental or abuse-related causes of falls. Depression and iron intake are less directly related to the symptoms described.
The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:
- A. Check the dressing for signs of bleeding.
- B. Empty any peri-incisional drains.
- C. Assess the client's pain level.
- D. Assess the client's bladder.
Correct Answer: C
Rationale: After confirming airway and vital signs, assessing pain level is the next priority, as uncontrolled pain can affect recovery and complicate other assessments or interventions.
The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations?
- A. Oxygen demand by the muscle exceeds the supply
- B. Oxygen demand and supply of the working muscle are in balance
- C. Oxygen supply exceeds the demand of the working muscle
- D. Oxygen is absent
Correct Answer: A
Rationale: Claudication in PVD results from insufficient blood flow to muscles during activity, causing oxygen demand to exceed supply, leading to pain. Nursing care should aim to improve blood flow (e.g., through exercise programs or medications) and avoid situations where muscle oxygen demand outstrips supply. Balanced or excess supply is desirable, and complete oxygen absence is not typical in claudication.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this beta-adrenergic blocker is to control glaucoma by:
- A. Constricting the pupils.
- B. Dilating the canals of Schlemm.
- C. Reducing aqueous humor formation.
- D. Improving the ability of the ciliary muscle to contract.
Correct Answer: C
Rationale: Timolol maleate, a beta-adrenergic blocker, reduces intraocular pressure by decreasing the production of aqueous humor in the eye.