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
Phenothiazines are contraindicated in patients with suspected or established subcortical brain damage. Phenothiazines are a class of drugs that have antipsychotic, antiemetic, and sedative effects. They act by blocking dopamine receptors in the brain and can cause extrapyramidal symptoms, hypotension, and anticholinergic effects.
Choice B is wrong because phenothiazines are not contraindicated in patients with ischemic heart disease.
However, they can cause orthostatic hypotension and cardiac arrhythmias, so they should be used with caution and monitored closely in these patients.
Choice C is wrong because phenothiazines are not contraindicated in pediatric patients.
However, they can cause sedation, hypotension, and extrapyramidal symptoms, so they should be used with caution and at lower doses in these patients.
Choice D is wrong because phenothiazines are not contraindicated in patients with type 2 diabetes.
However, they can cause hyperglycemia and weight gain, so they should be used with caution and monitored closely in these patients.
Correct Answer is A
Explanation
This is because phenothiazines are contraindicated in patients with suspected or established subcortical brain damage. Phenothiazines can cause central nervous system effects such as drowsiness, dizziness, and extrapyramidal symptoms that may worsen the condition of a client with a brain injury.
Choice B is wrong because phenothiazines are not contraindicated in clients with ischemic heart disease.
However, they should be used with caution as they can cause hypotension and cardiac arrhythmias.
Choice C is wrong because phenothiazines are not contraindicated in pediatric clients.
However, they should be used with caution as they can cause sedation, anticholinergic effects, and paradoxical excitement.
Choice D is wrong because phenothiazines are not contraindicated in clients with type 2 diabetes.
However, they should be used with caution as they can cause hyperglycemia and alter the effects of antidiabetic drugs.
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