A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?
Provide thickened fluids with a straw.
Listen to bilateral lung and bowel sounds.
Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function.
Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.
The Correct Answer is D
Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.
Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.
Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.
Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.
Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.
Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),
hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.
Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Choice A rationale: The lab results and clinical picture, such as weight loss, anorexia, and high blood glucose levels, point more toward a hyperglycemic state rather than severe hypoglycemia.
Choice B rationale: The client's elevated blood glucose levels, weight loss, and anorexia suggest a hyperglycemic state, possibly hyperosmolar hyperglycemic state, which requires fluid management and insulin to address the severe dehydration and high blood glucose levels.
Choice C rationale: Although high glucose levels are evident, the absence of significant acidosis (as seen in diabetic ketoacidosis) and extreme ketosis makes this diagnosis less likely.
Choice D rationale: The lab values and clinical presentation do not strongly align with a primary respiratory acidosis diagnosis, which typically involves changes in pH and carbon dioxide levels.
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