When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Breath sounds.

abdominal girth.

Bowel sounds.

Apical pulse.

Answer and Explanation

The Correct Answer is A

GERD can increase the risk of aspiration (inhalation of stomach contents into the lungs), which can cause respiratory issues, including abnormal breath sounds. In these cases, monitoring of breath sounds may be more appropriate than monitoring of bowel sounds.

Bowel sounds are not typically monitored for GERD patients as GERD is a condition that aﬀects the esophagus and the stomach, not the intestines. GERD is caused by the reﬂux of stomach contents into the esophagus, which can cause symptoms such as heartburn and regurgitation.

Abdominal girth is not routinely monitored for GERD patients as it is not typically related to the condition. GERD is a disorder that aﬀects the esophagus and stomach and does not typically cause significant changes in abdominal size or girth. In rare cases, GERD can be complicated by a condition known as a para oesophageal hernia, which can cause a visible bulge in the abdomen. In these cases, monitoring of abdominal size and shape may be necessary.

The apical pulse is not routinely monitored for GERD patients as it is not directly related to the condition. GERD is a disorder that aﬀects the digestive system, specifically the esophagus and stomach and does not typically have an impact on heart rate or rhythm.

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Correct Answer is C

Explanation

When teaching a patient with newly diagnosed GERD, the nurse will include that they will need to keep the head of their bed elevated on blocks. This helps prevent stomach acid from ﬂowing back into the esophagus while sleeping.

Peppermint tea might not be helpful in reducing GERD symptoms as it can relax the lower esophageal sphincter and worsen reﬂux.

Eating between meals is not recommended as it can increase acid secretion. Vigorous physical activities may increase the incidence of reﬂux.

A. encourage the patient to drink at least 3000 ml of ﬂuid a day. B. suggest that the patient increase dietary intake of foods that are high in fiber. C. inform the patient that a daily bowel movement is not necessary. D. perform a focused nursing assessment to identify risk factors for constipation.

Correct Answer is D

Explanation

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

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When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information will the nurse include when teaching a patient with newly diagnosed GERD?

Correct Answer is C

Explanation

A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

Correct Answer is D

Explanation

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