The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Thirst
Sore throat
Abdominal distention
Drowsiness
The Correct Answer is C
Choice A Reason:
Thirst is a common and expected symptom after an EGD, especially if the client has been fasting before the procedure. It does not typically indicate a complication and can be managed by gradually reintroducing fluids as tolerated. Therefore, thirst does not require further nursing assessment beyond routine post-procedure care.
Choice B Reason:
A sore throat is also a common symptom following an EGD. The procedure involves passing an endoscope through the throat, which can cause temporary irritation and discomfort. This symptom usually resolves on its own within a few days and does not indicate a serious complication. Therefore, a sore throat does not require further nursing assessment beyond providing comfort measures such as lozenges or warm saltwater gargles.
Choice C Reason:
Abdominal distention is a concerning symptom that requires further nursing assessment. It can indicate complications such as perforation, bleeding, or infection following the EGD. Perforation of the gastrointestinal tract is a rare but serious complication that can lead to peritonitis and sepsis if not promptly addressed. Therefore, any signs of abdominal distention should be reported to the provider immediately for further evaluation and intervention.
Choice D Reason:
Drowsiness is a common side effect of the sedatives used during the EGD procedure. It is expected that the client may feel drowsy or sleepy for a few hours after the procedure as the sedative wears off. This symptom does not typically require further nursing assessment unless it persists for an unusually long time or is accompanied by other concerning symptoms such as difficulty breathing or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Provide a quiet, low-stimulus environment
Choice A Reason:
Provide a quiet, low-stimulus environment
This is the correct answer. A quiet, low-stimulus environment helps to reduce the metabolic demands on the body and prevent overstimulation, which can trigger a thyroid crisis. Hyperthyroidism increases the body’s metabolic rate, and excessive stimulation can exacerbate symptoms and lead to a crisis. Therefore, creating a calm environment is crucial in managing hyperthyroidism and preventing complications.
Choice B Reason:
Keep the client NPO
Keeping the client NPO (nothing by mouth) is not typically necessary for preventing a thyroid crisis. While it may be required for certain procedures or if the client is experiencing severe symptoms, it is not a standard intervention for hyperthyroidism management. Therefore, this choice is not correct.
Choice C Reason:
Administer aspirin as prescribed for any sign of hyperthermia
Administering aspirin for hyperthermia is not recommended in clients with hyperthyroidism. Aspirin can increase free thyroid hormone levels by displacing thyroid hormones from their binding proteins, potentially worsening hyperthyroidism. Instead, other antipyretics like acetaminophen are preferred. Therefore, this choice is not correct.
Choice D Reason:
Observe the client carefully for signs of hypocalcemia
Observing for signs of hypocalcemia is not directly related to preventing a thyroid crisis. Hypocalcemia is more commonly associated with thyroidectomy or parathyroidectomy rather than hyperthyroidism itself. Therefore, this choice is not correct.
Correct Answer is A
Explanation
Choice A reason:
Baclofen is primarily used to treat muscle symptoms caused by multiple sclerosis, including muscle spasms, stiffness, and pain1. It acts on the spinal cord nerves to decrease the number and severity of muscle spasms, thereby improving muscle movement2. The effectiveness of baclofen in managing multiple sclerosis symptoms is best evaluated by assessing the reduction in muscle spasms.
Choice B reason:
While mood and affect are important aspects of a patient’s overall well-being, they are not the primary indicators of baclofen’s effectiveness. Baclofen does not have a direct impact on mood and affect, as its main function is to relieve muscle spasms and improve muscle movement.
Choice C reason:
Appetite is not a primary concern when evaluating the effectiveness of baclofen. This medication is not known to significantly affect appetite. The main therapeutic goal of baclofen is to reduce muscle spasms and improve mobility in patients with multiple sclerosis.
Choice D reason:
Sleep pattern, although important for overall health, is not the primary measure of baclofen’s effectiveness. Baclofen’s primary role is to alleviate muscle spasms and improve muscle function. While it may have some impact on sleep due to its muscle-relaxing properties, this is not the main criterion for evaluating its effectiveness.
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