A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Loose bowel movements.

Occult positive emesis.

Strong foul smelling flatus.

Report of poor night vision.

Answer and Explanation

The Correct Answer is B

B. Occult positive emesis refers to vomiting that occurs without the client's awareness, meaning that the vomitus may not be easily visible or readily apparent. Vomiting can lead to significant fluid loss and dehydration, which is particularly concerning in a client who has undergone a biliopancreatic diversion procedure (BDP).
A. Loose bowel movements may indicate gastrointestinal disturbances or malabsorption issues commonly seen after biliopancreatic diversion procedure (BDP). BDP involves rerouting a significant portion of the small intestine, which can affect digestion and absorption of nutrients and fluids.
C. Strong foul-smelling flatus may indicate bacterial overgrowth or malabsorption issues in the gastrointestinal tract, which can occur after BDP. While foul-smelling flatus can be uncomfortable and indicative of gastrointestinal disturbances, it may not require immediate intervention.
D. Poor night vision may suggest vitamin deficiencies, particularly deficiencies in fat-soluble vitamins such as vitamin A, which can occur after BDP due to reduced absorption of nutrients. While poor night vision should be addressed to prevent long-term complications, it may not pose an immediate threat to the client's health.

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Correct Answer is D

Explanation

D. Persistent pain following the resolution of herpes zoster, known as postherpetic neuralgia (PHN), is a common complication, especially in older adults. PHN can cause significant discomfort and affect the client's quality of life. Therefore, it is essential for the nurse to conduct a comprehensive assessment of the client's pain to better understand its characteristics, severity, duration, aggravating or alleviating factors, and impact on daily activities.
A. Patient education should follow a complete assessment of the pain to ascertain the diagnosis.
B. Performing a complete mental status exam is not indicated solely based on the client's report of persistent pain from herpes zoster.
C. Determining if the client has had a shingles vaccination is important for preventive healthcare, but it is not the priority action in addressing the client's current pain concern related to PHN. The focus should be on assessing and managing the client's pain to improve their comfort and well-being.

A. Administer a topical analgesic per protocol. B. Cleanse the tongue and mouth with swabs. C. Obtain a soft diet for the client. D. Encourage frequent mouth care.

Correct Answer is D

Explanation

D. Frequent mouth care helps maintain oral hygiene, reduces the risk of infection, and provides comfort to the client by removing debris and soothing irritated tissues.
A. Administering a topical analgesic may provide pain relief, but it should be done in accordance with the healthcare facility's protocol and after assessing the client's oral mucosa for any contraindications or precautions.
B. Cleaning the tongue and mouth with swabs can cause further irritation to the already sore oral tissues.
C. Obtaining a soft diet for the client is appropriate for minimizing trauma to the oral mucosa, but it may not address the immediate discomfort experienced by the client.

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A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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