The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Thirst
Sore throat
Abdominal distention
Drowsiness
The Correct Answer is C
Choice A Reason:
Thirst is a common and expected symptom after an EGD, especially if the client has been fasting before the procedure. It does not typically indicate a complication and can be managed by gradually reintroducing fluids as tolerated. Therefore, thirst does not require further nursing assessment beyond routine post-procedure care.
Choice B Reason:
A sore throat is also a common symptom following an EGD. The procedure involves passing an endoscope through the throat, which can cause temporary irritation and discomfort. This symptom usually resolves on its own within a few days and does not indicate a serious complication. Therefore, a sore throat does not require further nursing assessment beyond providing comfort measures such as lozenges or warm saltwater gargles.
Choice C Reason:
Abdominal distention is a concerning symptom that requires further nursing assessment. It can indicate complications such as perforation, bleeding, or infection following the EGD. Perforation of the gastrointestinal tract is a rare but serious complication that can lead to peritonitis and sepsis if not promptly addressed. Therefore, any signs of abdominal distention should be reported to the provider immediately for further evaluation and intervention.
Choice D Reason:
Drowsiness is a common side effect of the sedatives used during the EGD procedure. It is expected that the client may feel drowsy or sleepy for a few hours after the procedure as the sedative wears off. This symptom does not typically require further nursing assessment unless it persists for an unusually long time or is accompanied by other concerning symptoms such as difficulty breathing or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is a) 1 cup of milk.
Choice A reason: One cup of milk contains approximately 15 grams of carbohydrates. Milk is a good source of carbohydrates, protein, and calcium, making it a suitable option for maintaining blood glucose levels during exercise. It is important for individuals with diabetes to monitor their carbohydrate intake to manage their blood sugar levels effectively.
Choice B reason: Half a cup of regular ice cream contains around 15 grams of carbohydrates. However, ice cream also contains high levels of sugar and fat, which may not be the healthiest option for regular consumption, especially for individuals with diabetes. While it can be included occasionally, it is better to choose healthier carbohydrate sources.
Choice C reason: One slice of bread typically contains about 15 grams of carbohydrates. Bread, especially whole grain or whole wheat varieties, can be a good source of carbohydrates for individuals with diabetes. It provides fiber, which helps in maintaining stable blood sugar levels.
Choice D reason: One cup of sugar-free yogurt does not contain 15 grams of carbohydrates. Sugar-free yogurt usually has fewer carbohydrates compared to regular yogurt. It is important to read the nutritional labels to determine the exact carbohydrate content. Regular yogurt, on the other hand, can be a good source of carbohydrates.
Correct Answer is ["A","B","E"]
Explanation
Choice A: Nephropathy
Diabetic nephropathy is a common microvascular complication of diabetes mellitus. It is characterized by damage to the small blood vessels in the kidneys, leading to progressive kidney disease. The condition is often identified by the presence of protein in the urine (proteinuria) and can progress to end-stage renal disease if not managed properly. The primary mechanism involves hyperglycemia-induced damage to the glomeruli, the filtering units of the kidneys. This damage results in increased permeability and eventual scarring, impairing kidney function. Effective management of blood glucose levels and blood pressure is crucial in preventing or slowing the progression of diabetic nephropathy.
Choice B: Neuropathy
Diabetic neuropathy refers to nerve damage caused by chronic high blood sugar levels. It is another significant microvascular complication of diabetes. This condition can affect various types of nerves, including sensory, motor, and autonomic nerves. Symptoms may include pain, tingling, numbness, and loss of sensation, particularly in the extremities. Diabetic neuropathy can lead to severe complications such as foot ulcers and infections, which may necessitate amputation. The pathophysiology involves hyperglycemia-induced oxidative stress and inflammation, leading to nerve damage. Tight glycemic control and regular monitoring are essential in managing diabetic neuropathy.
Choice E: Retinopathy
Diabetic retinopathy is a leading cause of blindness among adults with diabetes. This microvascular complication involves damage to the small blood vessels in the retina, the light-sensitive tissue at the back of the eye. There are two main types: non-proliferative and proliferative retinopathy. Non-proliferative retinopathy is characterized by microaneurysms, hemorrhages, and exudates, while proliferative retinopathy involves the growth of new, fragile blood vessels that can bleed and cause retinal detachment. The primary cause is prolonged hyperglycemia, which damages the retinal blood vessels. Regular eye examinations and good glycemic control are vital in preventing and managing diabetic retinopathy.
Choice C: Peripheral Vascular Disease
Peripheral vascular disease (PVD) is not classified as a microvascular complication but rather a macrovascular one. It involves the narrowing or blockage of the blood vessels outside the heart and brain, primarily affecting the arteries in the legs. PVD is associated with atherosclerosis, where plaque builds up in the arterial walls, leading to reduced blood flow. Symptoms include leg pain, cramping, and ulcers. While PVD is a significant concern for individuals with diabetes, it is not considered a microvascular complication.
Choice D: Cerebral Vascular Disease
Cerebral vascular disease, which includes conditions such as stroke and transient ischemic attacks (TIAs), is also a macrovascular complication rather than a microvascular one. It involves the blood vessels supplying the brain and is primarily caused by atherosclerosis and hypertension. Diabetes increases the risk of cerebral vascular disease due to its association with other risk factors like high blood pressure and dyslipidemia. However, it is not classified as a microvascular complication.
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