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 D
Explanation
The correct answer is d. hypovolemic.
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
Correct Answer is B
Explanation
Choice A rationale:
Reducing the client's interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and worsen the client's agitation and delusions. It does not address the client's emotional distress.
Choice B rationale:
Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client's focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.
Choice C rationale:
Awakening the client earlier for daily morning care may further disrupt the client's sleep patterns and worsen agitation. It does not address the underlying issue of delusional thoughts and the client's emotional distress.
Choice D rationale:
Clarifying reality with the client about delusional thoughts can be counterproductive in dementia care. The client's cognitive impairment may make it challenging for them to understand or accept the clarification, leading to increased frustration and agitation. It is essential to use a more empathetic and therapeutic approach.
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