The community health nurse is performing a home visit for a 74-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. The client states to stop drinking water early in the day because it's just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response?

You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup.

You build up too much urine in your bladder, which can cause you to get confused.

Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake.

Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason: Dark-colored stools are an adverse effect of orlistat, a medication that blocks the absorption of fat in the intestines. The unabsorbed fat can cause the stools to become oily, foul-smelling, and dark in color. This can indicate a serious condition called steatorrhea, which can lead to malnutrition and vitamin deficiencies.

Choice B reason: Constipation is not an adverse effect of orlistat. In fact, orlistat can cause the opposite problem of diarrhea, especially if the client consumes too much fat in their diet. Constipation may be caused by other factors, such as dehydration, lack of fiber, or medication side effects.

Choice C reason: Nausea is not an adverse effect of orlistat. Nausea may be a symptom of other conditions, such as gastritis, gastroenteritis, or pregnancy. Nausea may also be caused by other medications, such as antibiotics, opioids, or chemotherapy drugs.

Choice D reason: Abdominal pain is not an adverse effect of orlistat. Abdominal pain may be a sign of other conditions, such as appendicitis, gallstones, or kidney stones. Abdominal pain may also be caused by other medications, such as NSAIDs, steroids, or oral contraceptives.

A. Intracorporeal lithotripsy B. Laparoscopic cholecystectomy C. Extracorporeal shock wave lithotripsy (ESWL) D. Methyl tertiary butyl ether (MTBE) infusion

Correct Answer is B

Explanation

Choice A reason: This is not a correct answer because intracorporeal lithotripsy is a procedure that uses a laser or an ultrasonic probe to break up gallstones inside the gallbladder or the bile ducts. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder.

Choice B reason: This is a correct answer because laparoscopic cholecystectomy is a surgery that removes the gallbladder through small incisions in the abdomen. It is the preferred treatment for cholecystitis, as it eliminates the source of inflammation and prevents further complications.

Choice C reason: This is not a correct answer because extracorporeal shock wave lithotripsy (ESWL) is a procedure that uses shock waves to break up gallstones outside the body. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may not be effective for all types of gallstones.

Choice D reason: This is not a correct answer because methyl tertiary butyl ether (MTBE) infusion is a procedure that uses a chemical solvent to dissolve gallstones inside the gallbladder. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may cause side effects such as nausea, vomiting, and liver damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is obese about orlistat. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

Correct Answer is A

Explanation

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo which preferred treatment?

Correct Answer is B

Explanation

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer)

A postoperative bariatric surgery client is complaining of nausea. Which intervention should the nurse facilitate?

A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?

Fluid and electrolyte balance is maintained through the process of fluid and solutes moving in and out of cells. What specific process allows fluid to pass through a membrane from a dilute to a more concentrated area?