A nurse is caring for a male client who is postoperative.
Which of the following client findings should the nurse identify as being consistent with dumping syndrome? Select all that apply.
Vital signs
Prescribed diet
Skin appearance
Blood glucose level
WBC count
Correct Answer : A,C,D
A. Vital signs. The client has a significantly elevated heart rate (110/min) and elevated blood pressure (178/82 mm Hg), both of which can be associated with autonomic responses in dumping syndrome. The dizziness and desire to lie down after eating are also classic symptoms. These signs reflect the body’s reaction to rapid gastric emptying and fluid shifts.
B. Prescribed diet. While a bland, soft diet is generally safe post-gastrectomy, it may not prevent dumping syndrome unless it includes specific modifications like low carbohydrate intake and small, frequent meals. However, this option alone does not directly indicate dumping syndrome.
C. Skin appearance. The client is noted to be diaphoretic and pale, which are common symptoms of dumping syndrome due to the vasomotor response and hypoglycemia that can follow rapid gastric emptying.
D. Blood glucose level. The client's fasting blood glucose dropped to 65 mg/dL, which is below the normal range. Hypoglycemia is a hallmark of late dumping syndrome, resulting from excessive insulin release after rapid carbohydrate absorption in the small intestine.
E. WBC count. The WBC count is within normal range (9,000/mm³) and does not indicate dumping syndrome or an infectious process. It is not relevant in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lorazepam. Lorazepam is a benzodiazepine and the first-line medication for treating status epilepticus due to its rapid onset of action. It acts by enhancing the effect of GABA, an inhibitory neurotransmitter, helping to quickly stop continuous seizure activity.
B. Carbamazepine. Carbamazepine is used for long-term seizure control, particularly in partial seizures, but it is not appropriate for emergency treatment of status epilepticus due to its slower onset of action and oral route of administration.
C. Lamotrigine. Lamotrigine is also used for chronic seizure management, including generalized and partial seizures. However, it is not effective in acute seizure emergencies and is typically not administered intravenously.
D. Clonazepam. While clonazepam is a benzodiazepine used to manage seizures, it is generally used for maintenance therapy. It lacks the fast-acting IV formulation preferred in treating status epilepticus, unlike lorazepam.
Correct Answer is D
Explanation
A. Discuss the client's preferences for determining a repositioning schedule. While it's important to consider the client's comfort, repositioning must follow clinical guidelines (typically every 2 hours) to prevent pressure injuries, especially in clients with limited mobility post-stroke.
B. Raise the side rails on both sides of the client's bed during repositioning. Raising both side rails can be considered a form of restraint if not medically justified. Only one rail should be raised for safety and support unless otherwise indicated by facility policy.
C. Reposition the client without the use of assistive devices. Repositioning a client post-stroke without proper equipment increases the risk of injury to both the client and the nurse. Assistive devices promote safety and proper body mechanics.
D. Evaluate the client's ability to help with repositioning. This is the first and most important step. Assessing the client’s physical capability and level of consciousness ensures that the nurse uses the appropriate technique and equipment for safe repositioning.
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