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When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
- A. Epigastric pain at night.
- B. Relief of epigastric pain after eating.
- C. Vomiting.
- D. Weight loss.
- E. Melena.
Correct Answer: A,C,E
Rationale: Gastric ulcers commonly cause epigastric pain at night, vomiting, and melena (dark, tarry stools) due to bleeding. Relief of pain after eating is more typical of duodenal ulcers, and weight loss is less common with gastric ulcers.
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The client has been taking magnesium hydroxide (milk of magnesia) at home in an attempt to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium-based antacids?
- A. Anorexia.
- B. Weight gain.
- C. Diarrhea.
- D. Constipation.
Correct Answer: C
Rationale: Magnesium hydroxide commonly causes diarrhea as an adverse effect, which the nurse should assess for with ongoing use.
The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.
Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
- A. Wear a patch over one eye.
- B. Place personal items on the sighted side.
- C. Lie in bed with the unaffected side toward the door.
- D. Turn the head from side to side when walking.
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
A client with rheumatoid arthritis is experiencing fatigue. Which nursing intervention is most appropriate?
- A. Encourage high-intensity exercise.
- B. Plan rest periods throughout the day.
- C. Increase carbohydrate intake.
- D. Limit fluid intake to reduce swelling.
Correct Answer: B
Rationale: Planning rest periods conserves energy and reduces fatigue in rheumatoid arthritis.