A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply)

“I will consume less caffeine and spicy foods"

"I will sleep with the head of my bed elevated”

"I will lie down for one half hour after meals”

“I will drink less fluid"

"I will try not to gain weight”

Answer and Explanation

Correct Answer : A,B,E

A. "I will consume less caffeine and spicy foods":
Spicy foods and caffeine can irritate the esophagus, exacerbating symptoms of hiatal hernia. Avoiding these can help in managing symptoms.

B. "I will sleep with the head of my bed elevated”:
Keeping the head elevated can prevent stomach acid from flowing back into the esophagus, reducing symptoms like heartburn. This is a helpful strategy for managing hiatal hernia.

C. "I will lie down for one half hour after meals”:
Lying down after meals can worsen symptoms because gravity can't help keep stomach acid in the stomach. Staying upright after eating helps prevent acid reflux.

D. "I will drink less fluid":There is no need to reduce fluid intake. Staying hydrated is important, and fluids do not typically contribute to hiatal hernia symptoms. However, drinking large amounts of fluid with meals should be avoided as it can increase stomach pressure.

E. "I will try not to gain weight”:
Maintaining a healthy weight is important. Excess weight can increase pressure on the abdomen, potentially worsening hiatal hernia symptoms.

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Correct Answer is D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

A. Headache B. Diarrhea C. Peripheral edema D. Dry mouth

Correct Answer is B

Explanation

A. Headache
Headache is not a common side effect of lactulose.

B. Diarrhea
Lactulose is a laxative often prescribed for patients with cirrhosis to prevent or treat hepatic encephalopathy. Its primary side effect is diarrhea, which helps remove excess ammonia from the body, a substance that can exacerbate encephalopathy in patients with liver disease.

C. Peripheral edema
Peripheral edema is not a typical side effect of lactulose.

D. Dry mouth
Dry mouth is not a typical side effect of lactulose.

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A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is collecting data from a client who has diverticular disease. The nurse should expect the client to report abdominal pain in which of the following locations?

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?