After years of struggling with weight management, a middle-aged adult client is evaluated for gastroplasty.
The client has experienced difficulty with managing diabetes mellitus and hypertension, but 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.
Apply sequential compression stockings.
Monitor for urinary incontinence.
Provide a wide variety of meal choices.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F","G","H","J"]
Explanation
Based on the provided information, the following assessment findings require immediate follow-up by the nurse:
- Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
- Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
- Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
- Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
- The client is pale: Paleness can be a sign of decreased oxygenation.
- Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
- Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.
Correct Answer is C
Explanation
Choice A rationale
Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.
Choice B rationale
Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.
Choice C rationale
Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.
Choice D rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.
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