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
Octreotide is a synthetic analog of somatostatin, a hormone that inhibits the secretion of growth hormone, insulin, glucagon, and other hormones. Octreotide can cause gastrointestinal side effects such as abdominal pain, diarrhea, constipation, nausea, vomiting, and flatulence. These side effects are more common and severe with the oral route than with the injectable route.
Choice B is wrong because tinnitus, or ringing in the ears, is not a common or serious side effect of octreotide.
Choice C is wrong because alteration in consciousness is not a common or serious side effect of octreotide.
However, octreotide can affect blood glucose levels and cause hypoglycemia or hyperglycemia, which can lead to confusion, dizziness, fainting, seizures, or coma in severe cases.
Choice D is wrong because changes in vision are not a common or serious side effect of octreotide.
However, octreotide can cause rare but serious eye problems such as blurred vision, double vision, eye pain, or blindness due to optic nerve damage or retinal detachment.
These eye problems require immediate medical attention.
Normal ranges for blood glucose are 70 to 100 mg/dL (3.9 to 5.6 mmol/L) for fasting and less than 140 mg/dL (7.8 mmol/L) for postprandial.
Correct Answer is A
Explanation
Tolbutamide is preferred for clients with renal dysfunction, who may not be able to excrete chlorpropamide, because it is more easily cleared from the body.
Choice B. Tolazamide is wrong because it is a first-generation sulfonylurea that is used less frequently and is usually tried after tolbutamide and chlorpropamide have been shown to be ineffective.
Choice C. Chlorpropamide is wrong because it is a first-generation sulfonylurea that may accumulate in clients with renal dysfunction and cause hypoglycemia.
Choice D. Chlorpromazine is wrong because it is an antipsychotic agent, not an oral antidiabetic agent.
First-generation sulfonylureas are oral antidiabetic agents that stimulate insulin secretion from the pancreas.
They are used to treat type 2 diabetes mellitus.
The normal range of blood glucose level is 70 to 110 mg/dL.
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