After years of struggling with weight management, a middle-age man is evaluated for gastroplasty.
He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery.
Which intervention is most important for the nurse to include in this client's plan of care?
Observe for signs of depression.
Monitor for urinary incontinence.
Provide a wide variety of meal choices.
Apply sequential compression stockings.
The Correct Answer is A
Choice A rationale:
Observing for signs of depression is the most important intervention for the nurse to include in the client's plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client's overall well-being and successful outcomes.
Choice B rationale:
Monitoring for urinary incontinence is not the top priority in this case. While it's important to assess and address urinary incontinence when necessary, it is not the most critical concern for a client undergoing gastroplasty. Depression and post-surgical complications related to weight management surgery take precedence.
Choice C rationale:
Providing a wide variety of meal choices is not the most important intervention at this stage. After gastroplasty, dietary choices are typically restricted, and the focus is on a controlled and healthy diet. The priority is addressing the psychological and emotional aspects of the client's care, as well as monitoring for surgical complications.
Choice D rationale:
Applying sequential compression stockings is not the most crucial intervention in this situation. While prophylaxis against deep vein thrombosis (DVT) is important, it is not the top priority compared to addressing potential depression and emotional well-being in a client who has struggled with weight management for years.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
Let’s calculate the infusion rate step by step:
- Convert 1 liter to mL: 1 liter = 1000 mL.
- Calculate total infusion time in minutes: 12 hours = 12 × 60 = 720 minutes.
- Calculate the rate in mL/min: Rate = Total Volume ÷ Total Time = 1000 mL ÷ 720 min = 1.39 mL/min.
- Calculate the drip rate in gtt/min: Drip Rate = Rate (mL/min) × Drip Factor (gtt/mL) = 1.39 mL/min × 15 gtt/mL = 20.85 gtt/min.
If rounding is required, we round to the nearest whole number. So, the nurse should regulate the infusion to 21 gtt/min.
Correct Answer is C
Explanation
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in technique.
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