Considering the patient's esophageal varices, which of the following nursing interventions would be appropriate in your care of the patient?
Encourage them to continue an exercise routine such as weightlifting.
Advise them to avoid straining at stools.
Provide them with hot liquids as desired.
Advise them to limit himself to one alcoholic drink per day.
The Correct Answer is B
Choice A reason: Encouraging the patient to continue an exercise routine such as weightlifting is not appropriate for a patient with esophageal varices. Weightlifting and other strenuous activities can increase intra-abdominal pressure, which may lead to the rupture of the varices and cause severe bleeding.
Choice B reason: Advising the patient to avoid straining at stools is the correct intervention. Straining during bowel movements can increase intra-abdominal pressure and the risk of rupturing the esophageal varices. The nurse should encourage the patient to maintain soft stools through a high-fiber diet, adequate hydration, and possibly stool softeners to prevent straining.
Choice C reason: Providing hot liquids as desired is not recommended for patients with esophageal varices. Hot liquids can cause vasodilation and potentially increase the risk of bleeding from the varices. Patients should be advised to consume beverages at moderate temperatures.
Choice D reason: Advising the patient to limit themselves to one alcoholic drink per day is not appropriate. Alcohol consumption can worsen liver disease, increase portal hypertension, and exacerbate esophageal varices. Patients with esophageal varices should be advised to avoid alcohol completely to reduce the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.
Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.
Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.
Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.
Correct Answer is A
Explanation
Choice A reason: Maintaining NPO (nothing by mouth) status is essential for patients with acute pancreatitis. This allows the pancreas to rest and decreases the secretion of pancreatic enzymes, reducing inflammation and promoting healing. NPO status is typically maintained until the patient's symptoms improve and the inflammation subsides.
Choice B reason: A soft, bland diet is not appropriate for the initial management of acute pancreatitis. Introducing food too early can stimulate pancreatic enzyme production and worsen inflammation. Once the patient stabilizes, dietary recommendations may include a gradual reintroduction of low-fat, bland foods.
Choice C reason: A regular diet is not suitable for patients with acute pancreatitis. Consuming a regular diet can exacerbate symptoms and inflammation by stimulating pancreatic enzyme secretion. Patients need to follow a more controlled dietary plan to manage their condition effectively.
Choice D reason: A low-fat, high-fiber diet is beneficial for general health but not for the initial management of acute pancreatitis. Once the patient's condition stabilizes and they are no longer NPO, a low-fat diet may be introduced gradually to avoid stimulating pancreatic enzyme production.
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