A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?
Provide three large meals a day.
Observe stool characteristics.
Evaluate intake and output.
Monitor laboratory reports of electrolytes.
The Correct Answer is A
Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.
Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inflammation in the gastrointestinal tract, evaluating intake and output can help to identify any fluid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.
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Correct Answer is B
Explanation
Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.
Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.
Correct Answer is A
Explanation
acromegaly typically causes an enlargement of the hands and feet. The nurse can inquire if the patient has noticed any changes in shoe size, as this may indicate abnormal growth.
"Are you experiencing tremors or anxiety" is not directly related to acromegaly, and although anxiety can be associated with some medical conditions, it is not a typical symptom of acromegaly.
"Is there any family history of acromegaly?" is also a relevant question, as acromegaly can be caused by a genetic disorder. If the patient has a family history of the condition, this may increase their risk of developing it.
"Have you had a recent head injury?" is not specifically related to acromegaly, although head trauma can cause a variety of medical conditions.
Overall, option a. is the most relevant question to ask a patient with suspected acromegaly.
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