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 D

Explanation

Choice A reason: Excessive stomach acid secretion is not the correct answer because it is not a diagnostic test, but a possible cause of peptic ulcer disease. Peptic ulcers are sores that develop in the lining of the stomach or duodenum due to damage from stomach acid and digestive enzymes.

Choice B reason: An incompetent pyloric sphincter is not the correct answer because it is not a diagnostic test, but a possible complication of peptic ulcer disease. The pyloric sphincter is a muscular valve that controls the passage of food from the stomach to the small intestine. If it becomes damaged or weakened, it can cause gastric outlet obstruction, which is a blockage of the stomach.

Choice C reason: A metabolic acid-base imbalance is not the correct answer because it is not a diagnostic test, but a possible consequence of peptic ulcer disease. Peptic ulcers can cause bleeding, perforation, or gastric outlet obstruction, which can affect the acid-base balance of the body. For example, vomiting can cause metabolic alkalosis, which is a condition where the blood is too alkaline.

Choice D reason: An infection with Helicobacter pylori is the correct answer. Helicobacter pylori is a type of bacteria that can infect the stomach and duodenum and cause inflammation and ulcers. It is the most common cause of peptic ulcer disease. The health care provider can order a diagnostic test to detect the presence of Helicobacter pylori in the client's stomach or blood, such as a urea breath test, a stool antigen test, or a blood antibody test.

A. Drink a carbonated beverage before bed B. Increase fatty foods one at a time C. Elevate the head of the bed when sleeping D. Eat dinner late in the evening

Correct Answer is C

Explanation

Choice A reason: This is not a correct instruction because drinking a carbonated beverage before bed can worsen the reflux symptoms by increasing the gastric pressure and the production of gas.

Choice B reason: This is not a correct instruction because increasing fatty foods can worsen the reflux symptoms by delaying the gastric emptying and relaxing the lower esophageal sphincter (LES), which allows the stomach acid to flow back into the esophagus.

Choice C reason: This is a correct instruction because elevating the head of the bed when sleeping can help prevent the reflux symptoms by using gravity to keep the stomach contents from flowing back into the esophagus.

Choice D reason: This is not a correct instruction because eating dinner late in the evening can worsen the reflux symptoms by increasing the amount and acidity of the stomach contents, which can easily flow back into the esophagus when lying down. The client should avoid eating within 3 hours of bedtime.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents to the clinic reporting vomiting and burning in her mid-epigastric area. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

Correct Answer is D

Explanation

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). Which instruction should the nurse give for management of this disease process?

Correct Answer is C

Explanation

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholelithiasis. Which of the following findings should the nurse expect?

A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

The healthcare provider ordered an IV solution for a dehydrated client with a skull fracture. The nurse knows which IV fluid would be contraindicated?

A client is suspected to have diverticulosis without symptoms of diverticulitis. Which diagnostic test should the nurse prepare the client to undergo?

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?

The nurse is caring for a client who has developed dumping syndrome while recovering from a bariatric surgery. What recommendation should the nurse make to the client?

The nurse is providing care for a client with a fluid imbalance. The nurse explains that in the body, areas with high concentration of solutes naturally and passively shift to areas of lower concentration. The nurse is describing which process?