The nurse is admitting a patient who is nauseated and vomiting up blood-streaked fluid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:
frequency of nonsteroidal anti-inflammatory drug (NSAID) use.
family history of gastric problems.
recent weight gain or loss.
amount of fat in the diet.
The Correct Answer is A
NSAIDs are known to be a common cause of acute gastritis. Therefore, it is essential for the nurse to ask the patient about their frequency of NSAID use to determine if this may have caused their current symptoms. Other options such as family history of gastric problems, recent weight gain or loss, and amount of fat in the diet, may also be relevant to the patient's overall health status, but they are not as important as the potential cause of their current condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.
Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inflammation in the gastrointestinal tract, evaluating intake and output can help to identify any fluid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.
Correct Answer is C
Explanation
The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.
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