Exhibits

The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of a disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Temperature: 98.9°F

Heart rate: 112 beats per minute

Respirations: 28 breaths per minute

Blood pressure: 130/86 mmHg

Oxygen saturation: 88%

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"}}

Temperature: 98.9°F

Neither Disease Process Nor Medication Use:
The temperature is within normal range and does not indicate an infection or other abnormality.

Heart Rate: 112 beats per minute

Disease Process:
The elevated heart rate (tachycardia) is most likely due to the asthma attack, which increases respiratory effort and oxygen demand. Anxiety from the attack could also contribute.

Respirations: 28 breaths per minute

Disease Process:
The elevated respiratory rate (tachypnea) is consistent with the asthma attack and respiratory distress, a hallmark of the disease process.

Blood Pressure: 130/86 mmHg

Neither Disease Process Nor Medication Use:
This value is slightly elevated but not significantly enough to be directly attributed to asthma or medication. It could be situational due to stress or anxiety.

Oxygen Saturation: 88%

Disease Process:
The low oxygen saturation is indicative of hypoxemia caused by bronchoconstriction and impaired gas exchange during the asthma attack.

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Correct Answer is C

Explanation

Choice A reason: Increased oral fluid intake is a general recommendation for clients with an infection to prevent dehydration and help thin respiratory secretions. While staying hydrated is important, it is not a specific change in blood glucose management for a client with diabetes and an upper respiratory infection.

Choice B reason: Restriction of caloric intake is not appropriate advice for a client with diabetes and an infection. During illness, the body’s metabolic needs increase, and caloric intake should be adjusted to meet these needs. Restricting calories can lead to inadequate nutrition and further complications.

Choice C reason: Higher doses of insulin are often needed for clients with diabetes who are experiencing an infection. Infections can cause increased stress on the body, leading to elevated blood glucose levels. The body’s inflammatory response and the release of stress hormones can result in insulin resistance and higher blood sugar levels. Therefore, it is common for healthcare providers to adjust insulin doses upward to manage these changes and maintain glycemic control during periods of illness.

Choice D reason: Fewer fingerstick glucose checks are not recommended. In fact, during illness, it is crucial for clients with diabetes to monitor their blood glucose levels more frequently. Close monitoring helps to detect hyperglycemia or hypoglycemia and allows for timely adjustments in insulin or other diabetes medications. Frequent glucose checks are essential for managing blood sugar levels effectively during illness.

A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort

Correct Answer is C

Explanation

Choice A reason: Encouraging the client to lie down and rest after meals is not advisable for someone with gastroesophageal reflux. Lying down after eating can exacerbate symptoms by allowing stomach acid to more easily flow back into the esophagus. It's recommended that clients stay upright for at least 2-3 hours after meals.

Choice B reason: Avoiding high-fiber foods is not a standard recommendation for managing gastroesophageal reflux. In fact, a diet high in fiber can benefit overall digestive health and help prevent constipation. The key dietary advice usually involves avoiding trigger foods such as spicy, fatty, or acidic foods.

Choice C reason: Elevating the head of the bed on blocks is an effective way to manage gastroesophageal reflux, especially at night. This position helps keep stomach acid in the stomach and prevents it from flowing back into the esophagus, reducing symptoms such as heartburn.

Choice D reason: Instructing the client to use antacids only as a last resort is not necessarily accurate advice. While antacids can provide symptomatic relief, they are often used as part of a comprehensive management plan for gastroesophageal reflux. However, lifestyle modifications and dietary changes are also crucial.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

Correct Answer is C

Explanation

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?

Correct Answer is C

Explanation

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