A client has begun reporting nausea and vomiting.
What would the nurse assess to determine the need for therapy?
Number of times client’s family reports the client is nauseated.
How well the client is eating.
Color and amount of vomit, and frequency of vomiting episodes.
Client’s nutritional status and fluid balance.
The Correct Answer is C
The nurse would assess these factors to determine the need for therapy. Some possible explanations for the other choices are:
Choice A. Number of times client’s family reports the client is nauseated.
This is not a reliable indicator of the severity or cause of nausea and vomiting.
The nurse should assess the client directly and not rely on the family’s reports.
Choice B. How well the client is eating.
This is not a specific or objective measure of nausea and vomiting.
The client may have other reasons for not eating well, such as loss of appetite, taste changes, or pain.
The nurse should also monitor the client’s weight, hydration status, and electrolyte levels.
Choice D. Client’s nutritional status and fluid balance.
These are important aspects of the client’s overall health, but they are not directly related to nausea and vomiting.
The nurse should assess these factors as part of the comprehensive care plan, but they are not sufficient to determine the need for therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should question the administration of human insulin to this client because they do not need exogenous insulin to maintain normal blood glucose levels. Human insulin is indicated for clients who have type 1 diabetes or type 2 diabetes that cannot be controlled by oral antidiabetic agents, diet, or exercise.
Choice A is wrong because a client who has been diagnosed with gestational diabetes may need human insulin to control their blood glucose levels during pregnancy, as oral antidiabetic agents are contraindicated.
Choice B is wrong because a client with type 2 diabetes, controlled with oral antidiabetic agents, who has a systemic infection may need human insulin to manage their blood glucose levels during periods of stress, as infection can increase blood glucose levels and impair the action of oral antidiabetic agents.
Choice D is wrong because a client who has been living with type 1 diabetes for 20 years needs human insulin to replace the endogenous insulin that their pancreas cannot produce.
Correct Answer is D
Explanation
Oxygen cannot diffuse rapidly across the membrane to tissues in the eye. This is because diabetic retinopathy is a condition that occurs when high blood sugar levels damage the tiny blood vessels that nourish the retina, the light-sensitive tissue at the back of the eye. As a result, the retina becomes ischemic (lacking oxygen) and tries to grow new blood vessels that are fragile and leaky.
Choice A is wrong because inability of cells in the eye to reproduce is not a cause of diabetic retinopathy.
The retina has a high metabolic rate and needs a constant supply of oxygen and nutrients to function properly.
Choice B is wrong because increase of aqueous humor in the eye is not a cause of diabetic retinopathy.
Aqueous humor is the clear fluid that fills the front part of the eye, not the retina.
An increase of aqueous humor can cause glaucoma, which is a different eye disorder that affects the optic nerve.
Choice C is wrong because decrease of nerve innervations throughout the eye is not a cause of diabetic retinopathy.
Nerve innervations are the connections between nerves and other tissues, such as muscles or glands.
Diabetic retinopathy affects the blood vessels, not the nerves, of the retina.
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