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 A
Explanation
Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.
Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.
Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.
Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.
Correct Answer is B
Explanation
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
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