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 nurse will include the instruction "Offer the client the commode or urinal every 2 hours" in the teaching plan for the client's family. This approach is known as timed voiding and can help the client re-establish a regular pattern of urination. Option "a" promotes frequent voiding, which helps
prevent accidents and promotes bladder health. Option "b" is not a recommended approach and can lead to dehydration, urinary tract infections, and other complications. Option "c" is also not recommended since holding urine for extended periods can lead to bladder distention and increase the risk of urinary tract infections. Option "d" is also not recommended since catheterization should only be considered in specific cases where other options have failed or are not feasible.
Correct Answer is C
Explanation
Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can fluctuate, so repeating the test will ensure that the client receives the appropriate treatment.
Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.
Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.
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