A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?
Provide thickened fluids with a straw.
Listen to bilateral lung and bowel sounds.
Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function.
Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.
The Correct Answer is D
Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.
Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.
Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.
Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Cri du chat syndrome involves a high-pitched cry in infants and other distinct physical and developmental features, but it doesn't present with the described symptoms.
Choice B rationale: Klinefelter syndrome, characterized by an extra X chromosome (XXY) in males, typically presents with small testicles, gynecomastia (enlarged breast tissues), sexual dysfunction, and altered body proportions, such as long legs and a shorter trunk, aligning with the client's symptoms.
Choice C rationale: Patau syndrome (Trisomy 13) manifests with severe developmental issues, facial abnormalities, and other physical malformations, but the described symptoms are not typically associated with this syndrome.
Choice D rationale: Turner syndrome involves females with a missing or partially missing X chromosome (45, X), resulting in specific physical features and medical problems not consistent with the described symptoms in a male client.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.
Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.
Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.
Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.
Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.
Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.
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