The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Prevent esophageal reflux.

Maintain intact oral mucosa.

Increase intestinal peristalsis.

Promote effective swallowing.

Answer and Explanation

The Correct Answer is A

Rationale for Choice A:

Direct (sliding) hiatal hernias: These are the most common type of hiatal hernia. They occur when the upper part of the stomach slides upward through the diaphragm into the chest cavity. This displacement disrupts the normal function of the lower esophageal sphincter (LES), which is a ring of muscle that acts as a valve between the esophagus and stomach. The LES is responsible for preventing stomach contents from refluxing back into the esophagus.

Esophageal reflux: When the LES is weakened or impaired, stomach acid, pepsin, and bile can flow back into the esophagus, causing a burning sensation known as heartburn, regurgitation of food or sour liquid, and irritation of the esophageal lining.

Prevention of esophageal reflux: Nursing actions aimed at preventing esophageal reflux are crucial in the management of hiatal hernias. These actions include:

Elevate the head of the bed: This helps to keep stomach contents below the level of the esophagus, reducing the risk of reflux. Avoid eating large meals: Large meals put more pressure on the stomach, which can increase the likelihood of reflux.

Avoid lying down after eating: Lying down can allow stomach contents to flow back into the esophagus more easily. Avoid foods that trigger reflux: Common triggers include fatty foods, spicy foods, acidic foods, caffeine, and alcohol.

Maintain a healthy weight: Excess weight can increase abdominal pressure and contribute to reflux.

Consider medications: If lifestyle changes are not enough to control reflux, medications such as antacids, H2 blockers, or proton pump inhibitors may be prescribed.

Rationale for Choice B:

Maintaining intact oral mucosa: This is not a primary goal in the care of a client with a hiatal hernia. While oral hygiene is important for overall health, it does not directly address the issue of esophageal reflux.

Rationale for Choice C:

Increasing intestinal peristalsis: This is not a relevant goal for a hiatal hernia. Hiatal hernias primarily affect the upper digestive tract, not the intestines.

Rationale for Choice D:

Promoting effective swallowing: This is not the most important goal in the care of a client with a hiatal hernia. While swallowing difficulties can occur in some cases, they are not the primary concern. The priority is to prevent esophageal reflux and its associated complications.

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Correct Answer is C

Explanation

Choice A rationale:

It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.

However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.

It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.

Choice B rationale:

While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.

Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.

Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.

Choice C rationale:

This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.

The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.

Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.

Choice D rationale:

While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.

Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.

Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.

A. Observe the skin for lesions. B. Palpate the lymph nodes. C. Palpate large joints for nodules. D. Observe the client’s fingers.

Correct Answer is D

Explanation

Choice A rationale:

Observing the skin for lesions is not a specific technique for assessing early signs of rheumatoid arthritis. While RA can sometimes manifest with skin lesions, they are not typically present in the early stages of the disease. Moreover, skin lesions can be indicative of a wide range of other conditions, making them a less reliable indicator of RA.

Choice B rationale:

Palpating the lymph nodes is also not a specific technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur in various inflammatory conditions, including infections and autoimmune diseases. It is not a characteristic feature of early RA.

Choice C rationale:

Palpating large joints for nodules is a technique used to assess for rheumatoid arthritis, but it is more likely to detect nodules in later stages of the disease. Nodules are typically firm, non-tender bumps that develop under the skin around joints. They are often found in areas like the elbows, knuckles, and fingers. However, they may not be present in the early stages of RA.

Choice D rationale:

Observing the client's fingers is the most appropriate technique for assessing early signs of rheumatoid arthritis. This is because the fingers are often the first joints to be affected by the disease. Early signs of RA in the fingers can include:

Swelling of the finger joints, particularly the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. Tenderness and pain in the finger joints, especially upon movement.

Stiffness in the finger joints, which is often worse in the mornings and after periods of inactivity. Redness or warmth in the finger joints.

Difficulty bending or straightening the fingers.

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The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection.Which response should the nurse provide?

Correct Answer is C

Explanation

Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Correct Answer is D

Explanation

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