The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
Abdominal cramping.
Bruising of the skin.
Low-grade fever.
Bloody emesis.
The Correct Answer is D
Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale
A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Replacing the IV site with a smaller gauge is not the most appropriate intervention in this situation. The client’s confusion and picking at the dressing and tape are likely due to the dementia and increased confusion at night, known as “sundowning”. While a smaller gauge might be less noticeable to the client, it does not address the primary issue of the client’s confusion and restlessness at night.
Choice B rationale
Applying soft bilateral wrist restraints might be considered in some situations to prevent a confused client from removing necessary medical devices. However, restraints should be a last resort after all other interventions have been tried because they can increase agitation and confusion, and they pose a risk for injury.
Choice C rationale
Redressing the abdominal incision is the correct choice. The dressing is no longer occlusive, which means it’s not providing a proper barrier to bacteria. This could lead to an infection in the surgical site. The nurse should clean the area and apply a new sterile dressing.
Additionally, the nurse should continue to monitor the client’s behavior and implement interventions to reduce confusion and restlessness, such as reorienting the client and providing a quiet and calm environment.
Choice D rationale
Leaving the lights on in the room at night can actually increase confusion and agitation in clients with dementia. It can disrupt the client’s sleep-wake cycle and make “sundowning” worse. Therefore, this is not the most appropriate intervention.
Correct Answer is A
Explanation
Choice A rationale
A firm crib mattress is crucial in reducing the risk of Sudden Infant Death Syndrome (SIDS). Soft surfaces can conform to the infant’s face and potentially block their airway, leading to suffocation.
Choice B rationale
Propping the infant with a pillow when in a side-lying position is not recommended as it increases the risk of SIDS. Infants should always be placed on their backs to sleep.
Choice C rationale
Swaddling the infant in a blanket for sleeping is not the most important measure to prevent SIDS. Overheating and loose bedding are risk factors for SIDS23.
Choice D rationale
Placing the infant in a prone position whenever possible is not recommended. Infants should always be placed on their backs to sleep to reduce the risk of SIDS23.
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