The community health nurse is performing a home visit for a 74-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. The client states to stop drinking water early in the day because it's just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response?

You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup.

You build up too much urine in your bladder, which can cause you to get confused.

Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake.

Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason: Colonoscopy is the most accurate diagnostic test for diverticulosis, which is the presence of pouches or sacs in the wall of the colon. It allows the direct visualization of the colon and the identification of any diverticula, polyps, or tumors. The nurse should prepare the client to undergo bowel preparation, sedation, and monitoring before and after the procedure.

Choice B reason: Magnetic resonance imaging (MRI) is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses a magnetic field and radio waves to create detailed images of the internal organs and tissues. It is more commonly used for brain, spine, joint, or soft tissue disorders.

Choice C reason: Abdominal ultrasound is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses sound waves to create images of the abdominal organs and structures. It is more commonly used for liver, gallbladder, kidney, or spleen disorders.

Choice D reason: Computed tomography (CT) scan with contrast is not a diagnostic test for diverticulosis. It is an invasive imaging technique that uses x-rays and a contrast dye to create cross-sectional images of the body. It is more commonly used for detecting tumors, abscesses, or bleeding. It is also used for diagnosing diverticulitis, which is the inflammation or infection of the diverticula.

A. The client quit smoking 6 months ago. B. The client has a strong family history of obesity. C. The client drinks six to eight cans of beer daily. D. The client has poorly controlled type 2 diabetes.

Correct Answer is C

Explanation

Choice A reason: The client quitting smoking 6 months ago is not a factor that would exclude her from being an appropriate surgical candidate. In fact, smoking cessation is a requirement for bariatric surgery, as smoking increases the risk of complications such as infection, thrombosis, and poor wound healing.

Choice B reason: The client having a strong family history of obesity is not a factor that would exclude her from being an appropriate surgical candidate. Family history is one of the genetic factors that can contribute to obesity, but it does not determine the eligibility for bariatric surgery. Other factors such as BMI, comorbidities, lifestyle, and motivation are more important.

Choice C reason: The client drinking six to eight cans of beer daily is a factor that would exclude her from being an appropriate surgical candidate. Alcohol abuse is a contraindication for bariatric surgery, as it can cause liver damage, malnutrition, dehydration, and addiction transfer. The client would need to abstain from alcohol for at least 6 months before and after the surgery.

Choice D reason: The client having poorly controlled type 2 diabetes is not a factor that would exclude her from being an appropriate surgical candidate. Type 2 diabetes is one of the comorbidities that can qualify a client for bariatric surgery, as it can improve or resolve after the surgery. However, the client would need to have a good glycemic control before the surgery to reduce the risk of complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is suspected to have diverticulosis without symptoms of diverticulitis. Which diagnostic test should the nurse prepare the client to undergo?

Correct Answer is A

Explanation

An adult female client has a body mass index of 34.5 kg/m2 and has expressed interest in bariatric surgery. What characteristic of the client's health status may exclude her from being an appropriate surgical candidate?

Correct Answer is C

Explanation

A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

The nurse is caring for a client who has developed dumping syndrome while recovering from a bariatric surgery. What recommendation should the nurse make to the client?

A client with diverticular disease has just returned from a colonoscopy. While conducting an abdominal assessment, the nurse monitors for which of the following as an initial sign of a possible complication of the procedure?

The healthcare provider ordered an IV solution for a dehydrated client with a skull fracture. The nurse knows which IV fluid would be contraindicated?

A nurse is caring for a client who has cholecystitis with cholelithiasis and obstruction of the common bile duct. The nurse should expect the client's urine to appear which of the following colors?

A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

A client presents to the clinic reporting vomiting and burning in her mid-epigastric area. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

A nurse is providing education to a client with GERD (gastroesophageal reflux disease). The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend?