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While performing a home visit, the nurse observes that the client’s head of the bed is raised on 6-in. blocks. The nurse should question the client for a history of which conditions?
- A. Hiatal hernia
- B. Dumping syndrome
- C. Crohn’s disease
- D. Gastroesophageal reflux disease
- E. Gastritis
Correct Answer: A, D
Rationale: Clients with a hiatal hernia are encouraged to sleep with the HOB elevated on 4- to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. B. Dumping syndrome occurs after surgery when the stomach no longer has control over the amount of chime that enters the small intestine. Clients are encouraged to lie flat after a meal. C. Crohn’s disease is an inflammatory disease of the bowel. Positioning interventions do not decrease symptoms. D. Clients with GERD are encouraged to sleep with the HOB elevated on 4— to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. E. Gastritis is inflammation of the gastric mucosa. Positioning interventions do not decrease symptoms.
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The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
- A. Ask the client to recall what she ate for the last 24 hours.
- B. Determine what type of birth control the client has been using.
- C. Reweigh the client to confirm the data.
- D. Take the client's pulse and blood pressure.
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.
Which outcome should the nurse identify for the client diagnosed with aphthous stomatitis?
- A. The client will be able to cope with perceived stress.
- B. The client will consume a balanced diet.
- C. The client will deny any difficulty swallowing.
- D. The client will take antacids as prescribed.
Correct Answer: C
Rationale: Aphthous stomatitis (canker sores) can cause painful swallowing, so denying difficulty swallowing is a key outcome. Stress coping and diet are secondary, and antacids are irrelevant.
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
Which statement made by the client indicates to the nurse the client may be experiencing GERD?
- A. My chest hurts when I walk up the stairs in my home.
- B. I take antacid tablets with me wherever I go.
- C. My spouse tells me I snore very loudly at night.
- D. I drink six (6) to seven (7) soft drinks every day.
Correct Answer: B
Rationale: Frequent use of antacids suggests ongoing heartburn or reflux symptoms, a hallmark of GERD. Chest pain with exertion is more suggestive of cardiac issues, snoring may indicate sleep apnea, and soft drink consumption is a risk factor but not a direct symptom.
Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series?
- A. Chalky white stools.
- B. Increased heart rate.
- C. A firm, hard abdomen.
- D. Hyperactive bowel sounds.
Correct Answer: A
Rationale: A UGI series uses barium, which can cause chalky white stools as it is excreted. Heart rate, abdominal firmness, and bowel sounds are not typically affected.