A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

Place an indwelling urinary catheter and attach a bedside drainage unit.

Send the client to x-ray for a flat plate of the abdomen.

Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Give a prescribed analgesic for temperature above 101° F (38.3°C).

Answer and Explanation

The Correct Answer is C

A.   An indwelling urinary catheter is generally used for monitoring urine output in patients with urinary issues or those who are unable to void. It is not the first-line intervention for a client with symptoms suggesting a possible bowel obstruction or gastrointestinal complication. While monitoring urine output may be important, it does not address the immediate concern of the client’s gastrointestinal symptoms.
B.   An abdominal x-ray can help diagnose conditions such as bowel obstruction, ileus, or other abdominal issues by visualizing the presence of air-fluid levels or distended bowel loops. While this diagnostic step is important, it should follow interventions that might provide immediate symptomatic relief or help manage the suspected condition.
C.   Inserting an NGT and attaching it to low intermittent suction is a critical intervention for managing symptoms of bowel obstruction or severe gastrointestinal distress. The dark brown, foul-smelling vomit and hyperactive bowel sounds suggest that the client might have a bowel obstruction or significant gastrointestinal complication. An NGT can help decompress the stomach, relieve pressure, reduce vomiting, and prevent further gastrointestinal complications.
D.   While providing analgesics for pain and fever is important for overall symptom management, it does not address the immediate cause of the client’s symptoms. The focus should be on diagnosing and managing the underlying issue causing the symptoms, such as a bowel obstruction, rather than just treating pain or fever.

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Correct Answer is B

Explanation

A. While assessing cognition is important for understanding the client’s overall functioning, the immediate issue of "freezing" during ambulation is more related to motor symptoms rather than cognitive impairment. "Freezing" in Parkinson's disease is a common motor symptom where the client feels as if their feet are glued to the floor.
B. The technique of pretending to step over an imaginary object (like a crack) is known to be a helpful strategy for managing "freezing" in Parkinson's disease. This technique provides a cognitive cue that can help the client initiate movement and overcome the freezing episodes. Confirming that this is an effective technique acknowledges the client's strategy and supports their efforts to improve mobility.

C. Reorienting the client to their location and circumstances can be helpful in situations where confusion or disorientation is an issue. However, in the case of "freezing" during ambulation, this response does not directly address the motor symptoms associated with Parkinson's disease. The problem here is more about movement initiation rather than orientation.
D. Moving to a carpeted area might help with traction and reduce the risk of slipping, but it does not directly address the issue of "freezing" episodes. The freezing phenomenon in Parkinson's disease is related to motor control rather than the type of flooring. While providing a safer walking environment is beneficial, it doesn’t target the underlying motor symptoms as directly as addressing the client’s technique.

A. "I can stop taking the phenytoin If I go for a while and don't have a seizure." B. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." C. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." D. “There are really no lifestyle changes that I can do that will affect my risk for having another seizure." E. "I may never know why! started having seizures."

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"I can stop taking the phenytoin If I go for a while and don't have a seizure." This statement indicates a lack of understanding. Anti-seizure medications are typically lifelong and should not be stopped without medical advice.

"Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement also shows a lack of understanding. A medic alert bracelet is crucial for individuals with seizures, as it provides essential information to emergency responders in case of an emergency.

"I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates a lack of understanding. Any seizure should be reported to a healthcare provider, as it could indicate changes in seizure control.

“There are really no lifestyle changes that I can do that will affect my risk for having another seizure." This statement indicates a lack of understanding. Certain lifestyle factors, such as sleep deprivation, stress, and alcohol consumption, can trigger seizures.

"I may never know why! started having seizures." This statement indicates understanding. While the cause of seizures is often unknown, it's important for the client to acknowledge this possibility.

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Naxlex Comprehensive Predictor Exams

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

Correct Answer is B

Explanation

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

The nurse establishes a nursing problem of "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care for this client?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?