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 in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
- A. Serum insulin level
- B. Heel stick blood glucose
- C. Rh and ABO blood typing
- D. Indirect and direct bilirubin levels
Correct Answer: B
Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth.
The nurse monitors a patient with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
- A. Inability to pass flatus
- B. Loss of anal sphincter control
- C. Severe, constant pain with rapid onset
- D. Firm, nontender mass palpable at the lower right costal margin
Correct Answer: A
Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Option 4 is the description of the physical finding of liver enlargement.
The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse should instruct the parents to take which measure?
- A. Restrict corn and rice in the diet.
- B. Restrict fresh vegetables in the diet.
- C. Substitute grain cereals with pasta products.
- D. Avoid foods that are hidden sources of gluten.
Correct Answer: D
Rationale: Gluten is found primarily in the grains of wheat, rye, barley, and oats. Gluten is added to many foods as hydrolyzed vegetable protein that is derived from cereal grains; therefore, labels need to be read. Corn and rice, as well as vegetables, are acceptable in a gluten-free diet, and corn and rice become substitute foods. Many pasta products contain gluten.
A client experiencing a severe major depressive episode is unable to address activities of daily living (ADL). Which nursing intervention best meets the client's current needs therapeutically?
- A. Have the client's peers approach the client about how noncompliance in addressing ADL affects the milieu.
- B. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADL.
- C. Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining her or his own ADL.
- D. Feed, bathe, and dress the client as needed until the client's condition improves so that she or he can perform these activities independently.
Correct Answer: D
Rationale: The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations.
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.