Nokea
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.
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The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
During a routine prenatal visit, a client in her third trimester of pregnancy reports having frequent calf pain when she walks. The nurse suspects superficial thrombophlebitis and checks for which sign associated with this condition?
- A. Severe chills
- B. Kernig's sign
- C. Brudzinski's sign
- D. Palpable hard thrombus
Correct Answer: D
Rationale: Pain in the calf during walking could indicate venous thrombosis or peripheral arterial disease. The manifestations of superficial thrombophlebitis include a palpable thrombus that feels bumpy and hard, tenderness and pain in the affected lower extremity, and a warm and pinkish red color over the thrombus area. Severe chills can occur in a variety of inflammatory or infectious conditions and are also a manifestation of pelvic thrombophlebitis. Brudzinski's sign and Kernig's sign test for meningeal irritability.
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. What should the nurse record as the client's PR interval?
- A. 0.12 second
- B. 0.20 second
- C. 0.24 second
- D. 0.40 second
Correct Answer: A
Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage?
- A. Lethargy
- B. Headache
- C. Erythematous rash
- D. Cardiac dysrhythmias
Correct Answer: D
Rationale: Stage II of Lyme disease develops within 1 to 3 months in most untreated individuals. The most serious problems in this stage include cardiac dysrhythmias, dyspnea, dizziness, and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy), muscle pain and stiffness, and a rash appear in stage I.