A nurse in a clinic is caring for a client who has gastroenteritis. The nurse compares the client's condition from two days ago and today. Which of the following changes should the nurse report to the provider?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's lungs are clear bilaterally.
The client's abdomen is soft and nontender.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these changes to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these changes to the provider as well, but they are not the most urgent ones.
Choice C reason: Clear lungs bilaterally are a normal finding and do not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Choice D reason: A soft and non-tender abdomen is a normal finding and does not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Strawberry yogurt is an appropriate food choice for a client who is taking phenelzine, as it does not contain tyramine, a substance that can interact with the medication and cause a hypertensive crisis. Yogurt is also a good source of protein, calcium, and probiotics, which can benefit the client's mood and health.
Choice B reason: Cheddar cheese is not an appropriate food choice for a client who is taking phenelzine, as it contains a high amount of tyramine, especially if it is aged or processed. Cheese and other dairy products that are high in tyramine should be avoided by the client, as they can cause severe hypertension, headache, nausea, and palpitations.
Choice C reason: Smoked salmon is not an appropriate food choice for a client who is taking phenelzine, as it contains a moderate amount of tyramine, especially if it is cured or fermented. Salmon and other fish or meat products that are high in tyramine should be limited or avoided by the client, as they can increase the blood pressure and heart rate.
Choice D reason: Pepperoni pizza is not an appropriate food choice for a client who is taking phenelzine, as it contains a low amount of tyramine, but it can accumulate if consumed in large quantities or with other tyramine-containing foods. Pepperoni and other sausages or deli meats that are high in tyramine should be consumed with caution by the client, as they can cause mild hypertension, flushing, and sweating.
Correct Answer is A
Explanation
Choice A reason: Positioning the newborn at a 20-degree angle after feeding can help prevent the reflux of gastric contents into the esophagus. This position allows gravity to keep the food in the stomach and reduces the pressure on the lower esophageal sphincter. The nurse should instruct the parent to keep the newborn in this position for at least 30 minutes after each feeding.
Choice B reason: Diluting formula with 1 tablespoon of water is not recommended, as it can cause water intoxication, electrolyte imbalance, and malnutrition in the newborn. Water intoxication can lead to seizures, coma, and death. The nurse should advise the parent to follow the manufacturer's instructions for preparing the formula and not to add extra water.
Choice C reason: Placing the newborn in a side-lying position if vomiting is not a safe practice, as it can increase the risk of aspiration and sudden infant death syndrome (SIDS). Aspiration is when food or liquid enters the lungs and causes pneumonia or respiratory distress. SIDS is when a healthy baby dies suddenly and unexpectedly during sleep. The nurse should instruct the parent to place the newborn on the back for sleeping and to avoid soft bedding, pillows, and stuffed animals.
Choice D reason: Providing a small feeding just before bedtime is not a good idea, as it can worsen the gastroesophageal reflux and disrupt the newborn's sleep. The nurse should suggest the parent to feed the newborn smaller and more frequent meals throughout the day and to avoid feeding the newborn within 2 to 3 hours of bedtime.
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