A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation
by the nurse is most effective to assist the client?
A) Losing weight.
B) Decreasing caffeine intake.
C) Avoiding large meals.
D) Raising the head of the bed on blocks. - CORRECT
ANSWER-D) Raising the head of the bed on blocks.
Rationale: Raising the head of the bed on blocks (D) (reverse
Trendelenburg position) to reduce reflux and subsequent
aspiration is the most effective recommendation for a client
experiencing severe gastroesophageal reflux during sleep.
(A, B and C) may be effective recommendations but raising
the head of the bed is more effective for relief during sleep.
,2|Page
The nurse is caring for a client with syndrome of inappropriate
antidiuretic hormone (SIADH), which is manifested by which
symptoms?
A) Loss of thirst, weight gain.
B) Dependent edema, fever.
C) Polydipsia, polyuria.
D) Hypernatremia, tachypnea. - CORRECT ANSWER-A) Loss
of thirst, weight gain.
Rationale: SIADH occurs when the posterior pituitary gland
releases too much ADH, causing water retention, a urine
output of less than 20 ml/hour, and dilutional hyponatremia.
Other indications of SIADH are loss of thirst, weight gain
(A), irritability, muscle weakness, and decreased level of
consciousness. (B) is not associated with SIADH. (C) is a
finding associated with diabetes insipidus (a water
metabolism problem caused by an ADH deficiency), not
SIADH. The increase in plasma volume causes an increase in
the glomerular filtration rate that inhibits the release of
rennin and aldosterone, which results in an increased
sodium loss in urine, leading to greater hyponatremia, not
(D).
,3|Page
The nurse is planning care for a client with newly diagnosed
diabetes mellitus that requires insulin. Which assessment should
the nurse identify before beginning the teaching session?
A) Present knowledge related to the skill of injection.
B) Intelligence and developmental level
of the client.
C) Willingness of the client to learn the injection sites.
D) Financial resources available for the equipment. - CORRECT
ANSWER-C) Willingness of the client to learn the injection
sites.
Rationale: If a client is incapable or does not want to learn,
it is unlikely that learning will occur, so motivation is the
first factor the nurse should assess before teaching (C). To
determine learning needs, the nurse should assess (A), but
this is not the most important factor for the nurse to assess.
(B and D) are factors to consider, but not as vital as (C).
The nurse is caring for a client who has taken a large quantity of
furosemide (Lasix) to promote weight loss. The nurse
anticipates the finding of which acid-base imbalance?
A) PO2 of 78 mm Hg
, 4|Page
B) HCO3 of 34 mEq/L
C) PCO2 of 56 mm Hg
D) pH of 7.31 - CORRECT ANSWER-B) HCO3 of 34 mEq/L
Rationale: Diuretics (non-potassium sparing) cause
metabolic alkalosis. A) PO2 of 78 mm Hg: This Po2
demonstrates mild hypoxemia, consistent with respiratory
disorders, not with diuretic use. C) PCO2 of 56 mm Hg:
CO2 retention results from hypoventilation, which is not
consistent with diuretic use. D) pH of 7.31: This pH is
acidotic; diuretics promote metabolic alkalosis.
The nurse is preparing a teaching plan for a client who is newly
diagnosed with Type 1 diabetes mellitus. Which signs and
symptoms should the nurse describe when teaching the client
about hypoglycemia?
A) Sweating, trembling, tachycardia.
B) Polyuria, polydipsia, polyphagia.
C) Nausea, vomiting, anorexia.
D) Fruity breath, tachypnea, chest pain. - CORRECT
ANSWER-A) Sweating, trembling, tachycardia.
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