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 D
Explanation
Glulisine is a rapid-acting insulin that has an onset of action of 2 to 5 minutes and peaks in 30 to 90 minutes, making it the fastest among the choices. Some possible explanations for the other choices are:
Choice A. Aspart is also a rapid-acting insulin, but it has a slightly longer onset of action (10 to 20 minutes) and peak time (1 to 3 hours) than glulisine.
Choice B. Lispro is another rapid-acting insulin, but it has a similar onset of action (<15 minutes) and peak time (30 to 90 minutes) as glulisine, so it is not the fastest.
Choice C. Regular is a short-acting insulin that has a much longer onset of action (30 to 60 minutes) and peak time (2 to 4 hours) than glulisine, so it is not suitable for fast therapeutic effects.
Normal ranges for blood glucose levels are 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Insulin doses are adjusted based on blood glucose monitoring, carbohydrate intake, physical activity, and other factors.
Correct Answer is D
Explanation
Choice A reason:
Injury sustained to the perineum during birth is not a perinatal injury, but a perineal injury. The perineum is the area between the anus and the genitals, and it can be torn or cut during vaginal delivery. This is a common complication that affects the mother, not the fetus or newborn.
Choice B reason:
Traumatic injury to the mother during pregnancy is not a perinatal injury, but a maternal injury. This can occur due to accidents, violence, or complications of pregnancy such as preeclampsia or placental abruption. This can affect the mother's health and well-being, and may also have consequences for the fetus or newborn.
Choice C reason:
Traumatic injury to a fetus is not a perinatal injury, but a fetal injury. This can occur due to external forces such as blunt trauma, penetrating trauma, or radiation exposure that affect the fetus in utero. This can cause fetal distress, bleeding, fractures, or organ damage.
Choice D reason:
Injury sustained surrounding birth is a perinatal injury. This occurs in the period shortly before, during, or after delivery. This can be a critical time when the baby has to transition from surviving off oxygen, blood, and nutrients from the mother to separating from the womb and breathing oxygen from the air. Perinatal injuries can include head injuries, nerve injuries, hemorrhages, fractures, or soft-tissue injuries that result from the forces of labor and delivery or medical interventions such as forceps or vacuum extraction. Perinatal injuries can lead to long-term neurodevelopmental challenges for the newborn.
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