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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The patient's bounding, rapid pulse and systolic hypertension may indicate cardiovascular complications associated with Graves' disease, such as tachycardia, atrial fibrillation, or congestive heart failure, which can cause chest pain. It is important for the nurse to assess for any symptoms of cardiovascular distress and report any abnormal findings to the healthcare provider for prompt intervention. Questions about appetite and constipation may be relevant to the patient's overall health status, but they are not the most important concern in this situation.

A. Schedule for IVP. B. Draw blood for blood urea nitrogen (BUN) and creatinine. C. Insert 16 French retention catheter. D. Administer lorazepam (Ativan) 0.5 mg.

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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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?

Correct Answer is A

Explanation

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Correct Answer is C

Explanation

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

A patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

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A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

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A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?