After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Auscultate for bowel sounds in all quadrants.

Measure the client's fluid intake and output.

Ask the client about gastrointestinal pain.

Monitor the client's serum electrolyte levels.

Answer and Explanation

The Correct Answer is C

A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.

B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.

C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.

D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.

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Correct Answer is D

Explanation

A. "Haven't you been feeding according to recommended daily allowances for children?": This response implies blame and lacks sensitivity. It doesn't acknowledge the child’s underlying medical condition that may affect growth.

B. "Does your child seem mentally slower than his peers also?": Intellectual development is unrelated to height/weight percentile in children with congenital heart disease unless there are neurological complications, which haven't been indicated.

C. "You should not worry about the growth tables. They are only averages for children.": While growth charts are averages, they are clinically significant, especially for identifying underdevelopment in children with chronic illnesses.

D. "The smaller size is probably due to the heart disease.": Chronic hypoxia and increased metabolic demands in congenital heart disease often contribute to poor weight gain and growth delay, making this the most informative and empathetic response.

A. "Risk for self-directed violence as evidenced by feelings of hopelessness." B. "Chronic low self-esteem as evidenced by feelings of worthlessness." C. "Anxiety as evidenced by abdominal discomfort secondary to depression." D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months."

Correct Answer is A

Explanation

A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.

B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.

C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.

D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.

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After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

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Naxlex Comprehensive Predictor Exams

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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