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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The patient's bounding, rapid pulse and systolic hypertension may indicate cardiovascular complications associated with Graves' disease, such as tachycardia, atrial fibrillation, or congestive heart failure, which can cause chest pain. It is important for the nurse to assess for any symptoms of cardiovascular distress and report any abnormal findings to the healthcare provider for prompt intervention. Questions about appetite and constipation may be relevant to the patient's overall health status, but they are not the most important concern in this situation.
Correct Answer is D
Explanation
One of the hallmarks of adrenal insufficiency is dehydration and decreased urinary output, which can lead to electrolyte imbalances such as hyperkalemia and hyponatremia. As treatment begins to take effect, the patient's fluid and electrolyte balance should improve, leading to an increase in urinary output. Acute adrenal insufficiency, also known as the Addisonian crisis, is a life-threatening condition caused by a sudden decrease in cortisol and aldosterone hormones. Treatment usually involves the administration of intravenous glucocorticoids and mineralocorticoids to replace the deficient hormones.
Decreasing serum sodium (a) and decreasing blood glucose (b) are not signs of improvement but rather indicative of continued adrenal insufficiency. Decreasing serum potassium (c) is also not a sign of improvement as it could indicate that the patient is developing hyperkalemia, which is a potential complication of adrenal crisis.
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