A client has begun reporting nausea and vomiting.
What would the nurse assess to determine the need for therapy?
Number of times client’s family reports the client is nauseated.
How well the client is eating.
Color and amount of vomit, and frequency of vomiting episodes.
Client’s nutritional status and fluid balance.
The Correct Answer is C
The nurse would assess these factors to determine the need for therapy. Some possible explanations for the other choices are:
Choice A. Number of times client’s family reports the client is nauseated.
This is not a reliable indicator of the severity or cause of nausea and vomiting.
The nurse should assess the client directly and not rely on the family’s reports.
Choice B. How well the client is eating.
This is not a specific or objective measure of nausea and vomiting.
The client may have other reasons for not eating well, such as loss of appetite, taste changes, or pain.
The nurse should also monitor the client’s weight, hydration status, and electrolyte levels.
Choice D. Client’s nutritional status and fluid balance.
These are important aspects of the client’s overall health, but they are not directly related to nausea and vomiting.
The nurse should assess these factors as part of the comprehensive care plan, but they are not sufficient to determine the need for therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because levothyroxine can increase the anticoagulant effect of oral anticoagulants and increase the risk of bleeding. The nurse should check the client’s prothrombin time and international normalized ratio (INR) regularly and report any abnormal values to the prescriber.
Choice B is wrong because hypothyroidism does not increase the risk of infection.
Choice C is wrong because hypothyroidism does not affect the level of consciousness unless it is severe and causes myxedema coma.
Choice D is wrong because hypothyroidism does not cause electrolyte imbalances.
Normal ranges for prothrombin time are 11 to 13.5 seconds and for INR are 0.8 to 1.22.
Correct Answer is B
Explanation
This is because a nutritious diet provides adequate fiber and nutrients for the GI tract, avoiding alcohol prevents dehydration and irritation of the GI mucosa, and cautious use of laxatives prevents dependency and electrolyte imbalance.
Choice A is wrong because caffeine can stimulate the GI motility and cause diarrhea or cramps.
Choice C is wrong because some prescription medications can affect the GI function, such as antibiotics, opioids, or antacids.
Increased fluid intake is good, but not enough to promote optimal GI function.
Vigorous exercise can also cause GI distress or dehydration.
Choice D is wrong because adequate fluid intake is essential for preventing constipation and maintaining hydration.
Exercise can also help with bowel movements and overall health.
Normal ranges for GI function vary depending on the individual, but generally, a person should have at least one bowel movement every 3 days and no more than 3 bowel movements per day.
The stool should be soft, formed, and easy to pass.
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